Carol S. Hodgson

Unprofessional Behavior in Medical School Is Associated with Subsequent Disciplinary Action by a State Medical Board

Purpose To determine if medical students who demonstrate unprofessional behavior in medical school are more likely to have subsequent state board disciplinary action. Method A case–control study was conducted of all University of California, San Francisco, School of Medicine graduates disciplined by the Medical Board of California from 1990–2000 (68). Control graduates (196) were matched by medical school graduation year and specialty choice. Predictor variables were male gender, undergraduate grade point average, Medical College Admission Test scores, medical school grades, National Board of Medical Examiner Part 1 scores, and negative excerpts describing unprofessional behavior from course evaluation forms, deans letter of recommendation for residencies, and administrative correspondence. Negative excerpts were scored for severity (Good/Trace versus Concern/Problem/Extreme). The outcome variable was state board disciplinary action. Results The alumni graduated between 1943 and 1989. Ninety-five percent of the disciplinary actions were for deficiencies in professionalism. The prevalence of Concern/Problem/Extreme excerpts in the cases was 38% and 19% in controls. Logistic regression analysis showed that disciplined physicians were more likely to have Concern/Problem/Extreme excerpts in their medical school file (odds ratio, 2.15; 95% confidence interval, 1.15–4.02; p = .02). The remaining variables were not associated with disciplinary action. Conclusion Problematic behavior in medical school is associated with subsequent disciplinary action by a state medical board. Professionalism is an essential competency that must be demonstrated for a student to graduate from medical school.

Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board.

Background In a previous study, we showed that unprofessional behavior in medical school was associated with subsequent disciplinary action. This study expands on that work by identifying the domains of unprofessional behavior that are most problematic. Method In this retrospective case-control study, negative comments were extracted from student files for 68 case (disciplined) and 196 matched control (nondisciplined) physicians. Comments were analyzed qualitatively and subsequently quantified. The relationship between domains of behavior and disciplinary action was established through chi-square tests and multivariate analysis of variance. Results Three domains of unprofessional behavior emerged that were related significantly to later disciplinary outcome: (1) poor reliability and responsibility, (2) lack of self-improvement and adaptability, and (3) poor initiative and motivation. Conclusions Three critical domains of professionalism associated with future disciplinary action have been defined. These findings could lead to focused remediation strategies and policy decisions.

A national study of medical student clinical skills assessment.

Background This study describes comprehensive standardized patient examinations in medical schools nationally. Method We surveyed 121 medical school curriculum deans regarding their use of standardized patient assessments. Questions addressed examination characteristics, funding sources, and collaborations. Results A total of 91 of 121 curriculum deans responded (75% response rate). The majority (84%) of respondents report conducting a comprehensive clinical skills assessment during the third or fourth year of medical school. Most programs are funded with dean’s office monies. Although many collaborate with other institutions for examination development, the majority of schools score and remediate students independently. Two-thirds of all respondents (61/91) report that the new standardized patient licensing requirement elevates the importance of in-house clinical skills examinations. Conclusions Most medical schools now conduct comprehensive clinical skills assessments after the core clerkships, and collaboration is common. These results suggest increasing emphasis on clinical and communication skills competency and opportunities for collaborative research.

Promoting Research in Medical Education at the University of California, San Francisco, School of Medicine

Over the past seven years, educational innovations and scholarship have flourished at the University of California, San Francisco, (UCSF) School of Medicine. Prior to 1998, there was no infrastructure to support educational research and yet a few faculty members published in medical education journals and were active in national professional associations. With the initiation of curriculum reform in 1998, a great deal of excitement about education was generated and innovative new educational programs were envisioned. These changes became opportunities for educational scholarship. With the development of an Office of Medical Education in 1997 and the Haile T. Debas Academy of Medical Educators in 2001, the infrastructure was in place to expand educational research and the scholarship of teaching. The components of this support include educational leadership, faculty development, the Teaching Scholars Program, the Office of Educational Research and Development, the Academy, a Fellowship in Medical Education Research, collaborative research, and extramural grants. As a result of these investments, the number of UCSF faculty members who are involved in educational research has increased significantly. There has been a four-fold increase in peer-reviewed articles published in medical education journals and a greater increase in the publication of educational abstracts, editorials, chapters, and books, plus presentations at U.S. professional association meetings. In this article, the authors describe the changes that have occurred at UCSF to achieve these results.

The relationship between measures of unprofessional behavior during medical school and indices on the California Psychological Inventory.

Background Research studies on physicians disciplined by state medical boards showed specific types of unprofessional behavior were predictive of later disciplinary action. Similarly, law enforcement officers who received disciplinary action scored lower on certain scales of the California Psychological Inventory (CPI). Method This study used a case–control descriptive design and independent t tests to examine differences in scores on six psychological indices (CPI scales) by level of unprofessional behavior during medical school. Results Physicians who demonstrated unprofessional behavior during medical school versus those who did not scored significantly lower on four CPI scales. Results are consistent with findings in which general unprofessional behavior during medical school can be further characterized to domains of irresponsibility, lack of self-improvement, and poor initiative. Conclusions The psychological indices of the CPI scales differed by level of unprofessional behavior, which leads one to wonder whether the use of personality measures should be considered during the admissions process to medical school.

Evaluating curricular effects on medical students' knowledge and self-perceived skills in cancer prevention.

Since the Report of the Project Panel on the General Professional Education of the Physician in 1980, there have been numerous recommendations for increasing attention to health promotion and disease prevention content in the medical student curriculum. The need for cancer prevention curriculum in particular was highlighted in the early 1990s, when a national survey by the American Association for Cancer Education indicated that 64% of the 1,038 faculty respondents felt that cancer prevention was underemphasized in their institutions’ medical student curricula. To put this in perspective, only 32% felt that cancer treatment was similarly underemphasized. Stimulated by a large percentage of UCLA graduating seniors indicating ‘‘inadequate’’ instruction in general prevention and screening on the 1996 AAMC Graduation Questionnaire and supported by a National Cancer Institute grant (R25 CA73914), we convened a panel of cancer control and prevention experts from four local institutions in 1997–98 to develop a set of instructional objectives to guide curricular revision in this area, ^http://www.medsch.ucla.edu/CaPrevent/competencies.pdf &. Using these objectives, a UCLA curriculum task force on cancer prevention worked with course directors to develop or revise instructional materials to emphasize cancer prevention, screening, and counseling. By January 2000, an enhanced cancer prevention curriculum had emerged to supplement existing instruction in cancer diagnosis and treatment and strategies for smoking cessation. In year one, we added two problem-based learning (PBL) cases and two standardized patient (SP) exercises, which focused on identifying risk factors and counseling for lifestyle change (for a total of 14 hours). In year two, we implemented a new SP case on breast cancer screening accompanied by a lecture on women’s cancer risks, and three hours of lecture on carcinogenesis (for a total of seven hours). In year three, we added computer-based simulations on skin cancer, a video and model for the prostate exam, and a SP case involving family counseling on breast cancer risk (for a total of seven hours). The present study was designed to evaluate the effects of this enhanced curriculum in cancer prevention on medical students’ knowledge and self-perceived competency in the use of counseling and screening examinations during each of the first three years of medical school. We also evaluated how three instructional strategies used—direct instruction, hands-on practice, and observation —contributed to these outcomes. Few studies exist in the literature evaluating this type of large-scale, multi-year curriculum project in cancer education.

Health care reform as perceived by first year medical students

Our study objective was to evaluate the attitudes of first year medical students toward the health care system using a self administered questionnaire to all first year medical students at the medical schools in the University of California system. Of 631 students surveyed, 94% comleted the instrument. Students were asked about their attitudes toward and familiarity with concepts in health services, access to care, and managed care. Our findings indicated that most students were unfamiliar with concepts related to health services. Students were concerned about access to care; sixty-six percent of students favor a national health insurance plan. A majority of students supported allowing patients access to the current health care system regardless of the cost or utility of a medical test or procedure. Thirty-nine percent felt that rationing health care in any form (transplants, access to the intensive care unit, etc.) is contrary to the way medicine should be practiced. 72% felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health costs, students identified reform of medical malpractice system (63%) and increased spending on preventive health (60%) as the two proposals most likely to be effective. Students generally held negative attitudes toward managed care organizations; only 10% would chose to receive their care in HMOs. We conclude that first year medical students generally have little understanding of the health care system. Despite this, they hold strong opinions about access to care, managed care organizations and strategies intended to reduce health care spending. It is up to medical educators to find creative methods of introducing these content areas into an already bulging curriculum.

Entering first-year medical students’ attitudes toward managed care

PURPOSE. To study the attitudes of entering first-year medical students toward reform of the U.S. health care system. METHOD. All 631 first-year medical students at the five medical schools in the University of California System were asked during orientation (late summer of 1992) to complete a self-administered questionnaire regarding their attitudes toward and knowledge about health care reform. Statistical methods used were chi-square tests and factor analyses. RESULTS. Of the 631 students, 594 (94%) responded. Of the respondents, 392 (66%) felt that there should be a national health insurance plan, and 428 (72%) felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health care costs, the students identified reform of the medical malpractice system (374, 63%) and increased spending on preventive health (356, 60%) as the most likely to be effective. The students generally held negative attitudes toward managed care organizations; only 59 (10%) indicated they would choose to receive care in health maintenance organizations. CONCLUSION. The students held strong opinions about access to care, managed care organizations, and strategies intended to reduce health care spending. Medical educators not only need to find creative methods of introducing these content areas into medical school curricula but should also anticipate the need for strategies to deal with negative attitudes held by students.

A fellowship in medical education to develop educational leaders

No abstract available.

The relationship between student anonymity and responses from two medical schools on the Association of American Medical Colleges' Graduation Questionnaire

Since the Association of American Medical Colleges (AAMC) began collecting data from graduating medical students in 1978, numerous studies have been published using data from the AAMC Graduation Questionnaire (GQ). Investigators have used the GQ to understand graduate career decisions and specialty choices or cited data from the GQ to document curricular deficiencies and evaluate outcomes. Medical schools often use the annual school report of their own GQ data to inform curricular discussions and stimulate change. Recently data have been made available online to supplement paper reports with graphic illustrations of multiple-year comparisons. In addition, the data can be purchased from the AAMC for analysis as SPSS data sets. When completing the questionnaire, students are asked for their permission to release their names so that their GQ responses can be merged with existing school data. This allows for a powerful curricular evaluation tool. For example, students’ GQ responses to questions about their preparation for practice can be merged with data from alumni who reflect on their medical school preparation. Do students selecting different careers evaluate the adequacy of curricular topics differently? Questions such as these can help schools better understand the quality and effectiveness of their curricula. Providing respondent anonymity or confidentiality is a characteristic method of survey data collection. Texts typically describe anonymity as the total separation of responses and respondents, whereas confidentiality allows the researcher to link responses to a respondent, (e.g. through name, unique identification), but the researcher promises not to do so in any way that would make an individual respondent identifiable. For example, confidential data allow the researcher to match an individual’s response on the GQ to data collected by the American Medical Association (AMA) Physician Profile through unique identifiers or respondent names, whereas anonymous data include no association between responses and respondents, rendering such a linkage impossible. Both these methods are advocated to increase response rates and improve honesty and accuracy in responding—especially to sensitive questions. However, confidentiality is considered less successful in this regard. Furthermore, those concerned with the protection of human subjects promote anonymity, while demanding confidentiality as a minimum standard. Anonymity places a number of restrictions on researchers. Anonymity severely limits the researcher’s ability to follow up and to ensure a representative response rate. In addition, it makes linking data, especially data collected at different times and in different settings, nearly impossible. For medical schools, the latter difficulty is the most problematic. Here we ask whether the perceived benefits of anonymity—particularly honesty in responding—warrant the limited use of results. Studies of the effects of anonymity versus confidentiality on responses have been contradictory. Most studies of anonymity have concluded that ensuring anonymity does not influence response rate. A review of 214 studies by Heberlein and Baumgartner found no benefit in the percentage responding when anonymous procedures were used. In terms of anonymity affecting subjects’ responses on a survey, 90% of respondents in a mail study self-identified by putting their return addresses on the envelope, yet their responses were comparable to the responses of those maintaining anonymity. Another study examining the effects of setting (home versus work) and anonymity (identifier versus no identifier) on teachers’ response rate, rapidity of response, and response about unions found no effect due to either the anonymity or the setting condition. Conversely, in another study, investigators compared college students’ satisfaction with counseling services after they had completed treatment. The 25% of the respondents who elected to self-identify reported higher levels of treatment satisfaction than did those remaining anonymous. In the medical education context, a recent study examined any biasing effects of non-response in a sample of 508 residents. Residents were asked to permit follow-up evaluations of their performances. Those granting permission had significantly higher mean scores on the Medical College Admission Test and higher medical school GPAs, indicating a clear source of nonresponse bias. Anonymity and response bias in surveys have always been a concern to investigators. In this study, we examined the scores of students who did and did not agree to release their names for the GQ survey to test whether GQ scores vary between the two groups of students, thereby introducing bias.