Cathy J. Lazarus

The Relationship Between Service Learning and Medical Student Academic and Professional Outcomes

Background: Little is known about the relationship between medical student participation in service and performance outcomes. Purpose: To examine relationships between involvement in required service learning and measures of academic and professional achievement and specialty choice. Methods: Using preexisting, self-reported data for Tulane University School of Medicines class of 2004, we categorized students as low, moderate, or high on commitment and involvement in service learning (CISL) and compared to multiple outcomes: class rank; election to the Alpha Omega Alpha (AOA) Honor Society; election to the Gold Humanism in Medicine Honor Society; total percent scores on 2 multistation, structured, clinical examinations; and specialty choice per 2004 residency match results. Results: Service learning involvement was related to class rank. There was a marginal relationship between CISL and election to AOA but no association with election to the Gold Humanism in Medicine Honor Society, Year 2 or 3 clinical skills examination results, or specialty choice. Conclusions: High participation in service learning and service learning leadership identify a group of students less likely to be in the top quartile of their class yet who are making important contributions to the community and profession.

The Program for Professional Values and Ethics in Medical Education.

Background: Medical educators are very interested in the teaching and evaluation of professional attitudes and behaviors among medical students, residents, and faculty. At Tulane University School of Medicine, we created the Program for Professional Values and Ethics in Medical Education (PPVEME) to return the focus of our curriculum to the physician-patient-community relationship and to the nurturing of professionalism. Description: PPVEME brings together students, residents, and faculty into learning teams that create longitudinal curricula about five themes: integrity, communication, teamwork, leadership, and service. The emphasis is on learner-driven self- and group-reflection about shared experiences, thus modeling essential professional attributes. Evaluation: The program is evaluated using surveys, student and faculty focus groups, and portfolios developed by student volunteers on each team. The first program event, a retreat for entering medical students, was highly successful. Conclusions: PPVEME is an attempt to construct a medical school learning environment around professionalism. Evaluation over time will tell how successfully that has been accomplished.

Required Service Learning for Medical Students: Program Description and Student Response

Background: Medical schools are in the process of examining their roles in training and preparing medical students for the changing world of health care. Many institutions are searching for ways to help promote positive relations between medical schools and the communities they serve. A form of experiential pedagogy called service learning is one way to accomplish such goals. Description: Tulane University School of Medicine implemented a required 20 hr of service learning for freshman medical students as part of an interdisciplinary longitudinal course, Foundations in Medicine. Evaluation: Community service hours and projects performed were tabulated over 3 years. A qualitative description of student feedback was undertaken. Conclusion: The program demonstrates that requiring service learning is acceptable to students, the medical school, and the community. The results show that required service learning has at least a short-term beneficial impact on students.

Peer nomination: a tool for identifying medical student exemplars in clinical competence and caring, evaluated at three medical schools.

Purpose Peer evaluation is underused in medical education. The goals of this study were to validate in a multiinstitutional study a peer nomination form that identifies outstanding students in clinical competency and interpersonal skills, to test the hypothesis that with additional survey items humanism could be identified as a separate factor, and to find the simplest method of analysis. Method In 2003, a 12-item peer nomination form was administered to junior or senior medical students at three institutions. Factor analysis was used to identify major latent variables and the items related to those characteristics. On the basis of those results, in 2004 a simpler, six-item form was developed and administered. Student rankings based on factor analysis and nomination counts were compared. Results Factor analysis of peer nomination data from both surveys identified three factors: clinical competence, caring, and community service. New survey items designed to address humanism are all weighted with interpersonal skills items; thus, the second major factor is characterized as caring. Rankings based on peer nomination results analyzed by either factor analysis or simply counting nominations distinguish at least the top 15% of students for each characteristic. Conclusions Counting peer nominations using a simple, six-item form identifies medical student exemplars for three characteristics: clinical competence, caring, and community service. Factor analysis of peer nomination data did not identify humanism as a separate factor. Peer nomination rankings provide medical schools with a reliable tool to identify exemplars for recognition in medical student performance evaluations and selection for honors (e.g., Gold Humanism Honor Society).

Using standardized patients to teach end‐of life Skills to Clinical Clerks

BACKGROUND This study examines the use of standardized patients to teach end-of-life skills to clinical clerks. METHODS Forty-four third-year clinical medical students participated in a half-day standardized patient workshop that was precepted by faculty members. The students were asked to report on their perceived abilities prior to the workshop and these were compared with post-workshop responses. The students were also asked to provide an overall evaluation of the standardized patient workshop as a learning experience. RESULTS The students uniformly found the workshop to be realistic, found the faculty facilitators to be helpful, and found the workshop effective in enhancing their end-of-life skills. Following participation in the workshop, students reported significant improvements in their perceived abilities to deal with pain, to appreciate cultural differences in the dying process, to deliver bad news, and to understand the legalities of do-not-resuscitate orders. CONCLUSIONS Standardized patient workshops are useful for teaching end-of-life skills.

The heart truth professional education campaign on women and heart disease: Needs assessment and evaluation results

BACKGROUND Heart disease is the leading cause of death for women in the United States. Research has identified that women are less likely than men to receive medical interventions for the prevention and treatment of heart disease. METHODS AND RESULTS As part of a campaign to educate healthcare professionals, 1245 healthcare professionals in 11 states attended a structured 1-hour continuing medical education (CME) program based on the 2004 AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women and completed a pretest and posttest evaluation. We identified significant knowledge deficits in the pretest: 45% of attendees would initially recommend lifestyle changes alone, rather than statin therapy, for women diagnosed with coronary artery disease (CAD); 38% identified statin therapy as less effective in women compared with men for preventing CAD events; 27% identified Asian American women at low risk (rather than high risk) for type 2 diabetes mellitus (DM); and 21% identified processed meat (rather than baked goods) as the principal dietary source of trans fatty acids. Overall, healthcare professionals answered 5.1 of 8 knowledge questions correctly in the pretest, improving to 6.8 questions in the posttest (p < 0.001). Family physicians, obstetrician/gynecologists, general internists, nurse practitioners/physician assistants, and registered nurses all statistically significantly improved knowledge and self-assessed skills and attitudes as measured by the posttest. CONCLUSIONS Significant knowledge deficits are apparent in a cross-section of healthcare providers attending a CME lecture on women and heart disease. A 1-hour presentation was successful in improving knowledge and self-assessed skills and attitudes among primary care physicians, nurse practitioners, physician assistants, and registered nurses.

Allowing Patients to Die: Practical, Ethical, and Religious Concerns

HERE’S THE CASE R.L. was a 58-year-old woman with a history of metastatic rectal carcinoma to lymph nodes and sacrum. Despite several attempts to control her disease with combination chemotherapy, she continued to have progressive disease and pain. Despite attempts to manage her pain as an outpatient, she was admitted to the hospital with extreme sacral bone pain for a continuous intravenous morphine infusion, titrated for pain relief. PAIN CONTROL There is a large and growing body of experience and consensus that good end-of-life care, including attention to physical, psychological, emotional, and spiritual needs, should be widely available in the United States. Indeed, this is the impetus behind the hospice concept, started in the United Kingdom by Dame Cicely Sanders in the 1950s. The United States Supreme Court, although they did not endorse physician-assisted suicide (PAS), upheld the right of all Americans to have good palliative care at the end of life, as stated in the landmark June 1997 decision (Vacco v Quill). 1 A major focus of end-of-life care is pain control. Long-acting opiates have the benefit of providing continuous pain relief throughout their duration of action. For patients with severe pain (that has not been relieved in the outpatient setting) or for patients with acute pain syndromes, admission to the inpatient setting for titration of a continuous infusion of opiates may be necessary. R.L. had been treated with oral long-acting morphine, at a dose of 1,000 mg by mouth every 8 hours as an outpatient. She also had been receiving immediate-relief oral morphine tablets for breakthrough pain. Because the highest dose available in a single long-acting morphine tablet is 200 mg, she was thus taking 15 tablets daily. Given her current morphine dose and her severe pain, her initial infusion was set at 60 mg/h. She was also allowed additional intravenous morphine boluses of 10% of her total 24-hour maintenance dose every 15 minutes as needed. R.L. had good pain control with the intravenous morphine and other supportive medications. However, 2 days into her hospitalization, she began to feel quite anxious. Her anxiety was believed, in part, to be due to the high dose of intravenous morphine that she was receiving, but it also appeared to have a psychologic component. Specifically, she was concerned about being a burden for her family and concerned about her family’s burden of finalizing her affairs after her death. She had difficulty sleeping. ANXIETY CONTROL

A student-initiated and student-facilitated international health elective for preclinical medical students

Introduction: Global health education is becoming more important for developing well-rounded physicians and may encourage students toward a career in primary care. Many medical schools, however, lack adequate and structured opportunities for students beginning the curriculum. Methods: Second-year medical students initiated, designed, and facilitated a pass–fail international health elective, providing a curricular framework for preclinical medical students wishing to gain exposure to the clinical and cultural practices of a developing country. Results: All course participants (N=30) completed a post-travel questionnaire within one week of sharing their experiences. Screening reflection essays for common themes that fulfill university core competencies yielded specific global health learning outcomes, including analysis of health care determinants. Conclusion: Medical students successfully implemented a sustainable global health curriculum for preclinical student peers. Financial constraints, language, and organizational burdens limit student participation. In future, long-term studies should analyze career impact and benefits to the host country.

Physician Practice Behavior and Practice Guidelines: Using Unannounced Standardized Patients to Gather Data

BackgroundMeasuring actual practice behaviors of physicians, particularly as they relate to established clinical guidelines, is challenging. Standardized patients provide one method of collecting such data.ObjectiveTo demonstrate the use of unannounced standardized patients in gathering data that may address adherence to guidelines in an office setting.DesignUnannounced standardized patients (SPs) simulating an initial type 2 diabetic visit presented to community offices of 32 internists as “real” patients to record physicians’ evaluation and management.ParticipantsUnannounced SPs presented to the office of 32 internists as “real” patients.MeasurementsUnannounced SPs, simulating type 2 diabetics, completed a standardized assessment sheet, based on ADA guidelines to record physicians’ evaluation and management following an initial visit. Patient charts were also reviewed to determine if evaluation adhered to the guidelines.ResultsUnannounced SPs recorded 56 visits with 32 community internists; all SPs remained undetected. All physicians asked SPs about medications. At least 50% of physicians asked about home blood sugar monitoring, last eye exam, smoking, edema, and told patients to stop smoking. Less than 50% of physicians asked about parasthesias, performed fundoscopy, examined feet, referred the patient to a diabetic educator or ophthalmologist, or gave patients suggestions regarding glucose monitoring or exercise. HbA1c was ordered in 78%, metabolic profiles in 86%, and urinalysis/microalbumin in 41% of patients.ConclusionsUnannounced standardized patients can successfully collect important data regarding physician practices in community settings. This method may be helpful in assessing physician adherence to established clinical practice guidelines.

Reflections of Medical Student Service Leaders: Implications for Admissions and Curriculum

Seventy-five students from five medical schools participated in structured interviews to elicit their community service history and opinions regarding the relationship of community service to the medical school admissions process and the medical school curriculum. An analysis of responses indicates that service leaders were: (a) influenced by family, church, or peers to participate in community service activities at an early age; (b) demonstrated interest in service activities through depth of commitment and assumption of a leadership role; (c) recognized that time conflicts hampered service participation during medical school; and (d) did not think that service experiences in medical school should be required. Results of this study are of value to admissions officers trying to select medical school applicants with a service commitment and to educators seeking to promote community service activity in their student body. The study underscores the impact of institutional commitment to service on the “professionalization” of physicians.