Carmi Z. Margolis

A new approach to developing cross-cultural communication skills

The need for cross-cultural training (CCT) increases as physicians encounter more culturally diverse patients. However, most medical schools relegate this topic to non-clinical years, hindering skills development. Some residency programs have successfully addressed this deficit by teaching cross-cultural communication skills in a teaching objective structured clinical examination (tOSCE) context. The authors developed and evaluated a CCT workshop designed to teach cross-cultural communication skills to third-year medical students using a tOSCE approach. A 1½-day workshop incorporating didactic, group discussion and tOSCE components taught medical students cross-cultural awareness, interviewing skills, working with an interpreter, attention to complementary treatments, and consideration of culture in treatment and prevention. Six standardized patient cases introduced various clinical scenarios and the practical and ethical aspects of cross-cultural care. Student evaluation of the workshop was positive concerning educational value, skills advancement and pertinence to their clinical activities. Survey of students before and after the workshop demonstrated improvement in students’ abilities to assess the culture and health beliefs of patients and negotiate issues regarding treatment. CCT in the context of medical student clinical training can be carried out effectively and efficiently using a dedicated multi-modal workshop including standardized patients.

Clinical Practice Guidelines at an HMO: Development and Implementation in a Quality Improvement Model

Harvard Community Health Plan (HCHP) is adapting to clinical medicine the managerial principles and methods of quality improvement theory that were originally developed and successfully applied in industrial settings. An essential step in applying the quality improvement cycle to clinical medicine is the setting of standards or specifications for clinical care. HCHP has chosen to focus its standard-setting efforts on the development of clinical algorithms, which provide an excellent basis for specifying and communicating optimal care processes and for evaluating actual clinical care. When implemented effectively, clinical algorithms may improve quality and decrease costs by guiding clinicians toward more standardized, high-quality, cost-effective clinical strategies and by facilitating more valid measurement of clinical process and outcomes. This article describes the evolution, structure, methods, and future agenda of the Algorithm Based Clinical Quality Improvement Process (ABCQIP) at HCHP.

Computerized Algorithms and Pediatricians' Management of Common Problems in a Community Clinic.

In 1987, a microcomputer clinical algorithm (CA) system for constructing and using CAs for patient care was designed and implemented for six common primary care pediatrics problems. Six community clinic pediatricians agreed to use the system for several months. Length of patients visit, completeness of data collection, antibiotic use, and appropriateness of clinical plan were measured before the computers were introduced (without CAs) and after the computers were introduced (both with and without CAs). All performance measures improved after the introduction of CAs. However, CA implementation had to be discontinued after five weeks because the CAs were too tedious for the physicians to follow during routine care. The authors conclude that CAs cannot be successfully sustained with physicians for common problems, even though their design and use can significantly improve the process of care.

Is Consensus Reproducible?: A Study of an Algorithmic Guidelines Development Process

The authors evaluated the reproducibility of a clinical algorithm consensus development process across three different physician panels at a health maintenance organization. Physician groups were composed of primary care internists, who were provided with identical selections from the medical literature and first-draft “seed” algorithms on the management of two common clinical problems: acute sinusitis and dyspepsia. Each panel used nominal group process and a modified Delphi method to create final algorithm drafts. To compare the clinical logic in the final algorithms, the authors applied a new qualitative and quantitative comparison method, the Clinical Algorithm Patient Abstraction (CAPA).Dyspepsia algorithms from all physician groups recommended empiric anti-acid therapy for most patients, favored endoscopy over barium swallow, and had very similar indications for endoscopy. The average CAPA comparison score among final physician algorithms was 6.1 on a scale of 0 (different) to 10 (identical). Sinusitis algorithms from all groups proposed empiric antibiotic therapy for most patients. Indications for sinus radiographs were similar between two algorithms (CAPA = 4.9), but differed significantly in the third, resulting in lower CAPA scores (average CAPA = 1.9, P < 0.03).The clinical similarity of the algorithms produced by these physician panels suggests a high level of reproducibility in this consensus-driven algorithm development process. However, the difference among the sinusitis algorithms suggests that physician consensus groups using a consensus process that a health maintenance organization can do with limited resources will produce some guidelines that vary due to differences in interpretation of evidence and physician experience.

Guiding principles for the development of global health education curricula in undergraduate medical education

Background: Global health education (GHE) at undergraduate medical institutions has expanded significantly over the last 30 years, but many questions remain regarding the best practices for the development and implementation of global health programs. Aim: To identify key themes essential to the development of GHE programs. Method: We discuss five themes relevant to GHE in the context of existing literature and practice. Results: The following themes are essential to the development of GHE programs: the definition and scope of GHE, student competencies in global health, the challenges and opportunities associated with inter-institutional relationships, principles for GHE student placements, and the evaluation of GHE programs. We place these themes in the context of current literature and practice, and provide practical guidance on how these themes might be successfully implemented by institutions seeking to develop or refine GHE programs. Conclusions: Institutions developing or evaluating GHE programs should focus on these themes as they build their global health curricula.

Criteria map audit of scorpion envenomation in the Negev, Israel

A criteria map audit is a medical record audit in which quality of care is evaluated according to algorithmically arranged criteria. Thus, a particular criterion is applied to the patient record only if other criteria have been met. For example, if a stung childs condition is severe but not life threatening and if he has had a positive skin test for antivenom sensitivity then he should receive antivenom only after receiving adrenaline and hydrocortisone. We used a modified criteria map audit to determine both the clinical picture of scorpion envenomation and quality of care process in 94 children. Related outcomes of care measured included mortality, persistent morbidity, allergic reaction to scorpion antivenom and length of stay in hospital. Scorpion stings in the Negev region are usually due to the yellow scorpion, L. quinquestriatus, and usually occur in the summer months on the extremities in exposed male children under 10. The clinical picture is more severe when the scorpion is yellow, when the child is younger and when the sting is on the trunk or head. Symptoms apparently mediated by the central nervous system (2.6 findings/child) were more frequent than parasympathetic symptoms (2.3 findings/child). Treatment with antivenom and specific therapy for complications led to very low persistent morbidity and mortality in symptomatic cases, but was also accompanied by a longer hospital stay (64% equal to or greater than 3 days) than for asymptomatic cases (18% equal to or greater than 3 days). Testing for antivenom sensitivity was omitted in an unacceptably high percentage of cases (69%) and its omission led to an allergic reaction in 4 out of 40 cases (10%). Inadequacy in treatment of 7 secondary clinical problems ranged from 71% for hypertension to 29% for seizures (mean 46%). Persistent morbidity was negligible and mortality was 1.2%. We conclude that criteria map audit can be used to describe the clinical and epidemiological picture of a clinical problem while at the same time providing an audit of the process of care.

Community-based medical education.

Community-based education refers to teaching health care personnel in the community or in primary care hospital settings. In the early 20th century, Osler (1958), inventor of the clinical clerkship as we know it, had students at Johns Hopkins rotate ® rst through general hospital clinics and only afterward work on the wards. However, by the middle of the century most of the medical student’s clinical experience took place during hospital ward rotations. It was felt that learning the complete hospital admission history and physical examination and managing ward patients with their rapidly changing, complex illnesses was the basic ® rst step in quality clinical training. Only with the coming of academic primary care pediatrics, primary care internal medicine and family medicine in the late 1960s and early 1970s did some schools begin to rethink the advantages of general ambulatory or community-based training and the disadvantages of exclusively hospital-based training (Schmidt et al., 1989). These same community-oriented schools in Canada, the Netherlands, the United States and Israel emphasized not only a primary care but also a community approach to a patient’s problems. Some of these schools went so far as to emphasize improving the health of the population in their immediate geographical area. Over the last quarter of the 20th century, this shift in emphasis on the importance of the community has gradually increased. In the last 5 years, emphasis on managed care as a main source of healthcare in the USA has intensi® ed the community orientation of almost all medical schools. In response to the re-examination of the academic health center and health professional school mission (Seifer, 2000) by the Council on Graduate Medical Education and the Pew Foundation in the USA, by the General Medical Council in Great Britain and by the World Federation for Medical Education and by Boelen (1992) from a global perspective, there has been considerable investment in curricular reform and in using ambulatory and community-based settings for teaching. This paper aims to de® ne the goals, methods and the approach to evaluation of community-based education from a quality improvement perspective.

Evaluation of student attitudes and knowledge in a new program in international health and medicine

Ben-Gurion University (BGU) in collaboration with Columbia University inaugurated a medical school in 1998, with the expressed purpose of training physicians in International Health and Medicine (IHM). The Beer-Sheva Survey of Attitudes and Knowledge in International Health and Medicine was given to the first graduating class and three control groups. The graduates of the new program retained their positive attitudes toward IHM and increased their knowledge of the subject. Further studies are necessary to document the effect of the program on the clinical practice of its graduates.

Clinical algorithms teach pediatric decisionmaking more effectively than prose.

Despite the rapidly increasing volume of medical literature, little attention has been paid to the appropriate printed format for teaching clinical content. This study attempted to determine whether a clinical algorithm (CA) or prose is more effective for teaching clinical decisionmaking. Clerkship students, preclerkship students, and pediatric house officers in five medical centers in the USA and Israel were presented with clinical algorithms and prose describing management of fever in a child under 2 years of age, and management of meningitis in children. Knowledge of decisionmaking was measured before and after learning, using audio-taped clinical problems and learning time as measured. It was concluded that CAs are more effective and more efficient than prose for teaching clinical decisionmaking. When writing about clinical decisionmaking, the use of CAs should always be considered, especially if a series of interdependent decisions is being described.

Text-to-algorithm Conversion to Facilitate Comparison of Competing Clinical Guidelines

This study aimed to test the usefulness and reliability of text-to-algorithm conversion in comparing competing clinical guidelines and defining their differences. Two pairs of competing guidelines for measles immunization, published in 1989 and 1994, were analyzed and compared. Five categories of differences were detected: differences in recommendations, excluded elements, logical inconsistencies, nonspecific phrases, and approaches to contraindications. On a scale of 0-10 (where identical = 10), the overall comparison scores were 6.01 for the guidelines published in 1989 and 5.54 for the guidelines published in 1994. Text-to-algorithm conversions performed by three different persons on the 1989 guidelines were compared and found similar. Text-to- algorithm conversion is an important step in facilitating comparison of competing guide lines. It has the potential to assist in making rational and systematic choices between competing guidelines before actual field testing takes place. Physicians can use it to analyze and to learn a prose clinical guideline, to critique existing guidelines, and to simulate hypothetical patients for teaching and evaluating clinical management. Key words: medical decision making; clinical guidelines; clinical algorithms; health services evaluation; semantic analysis; measles immunization. (Med Decis Making 1998;18: 304-310)