Charles H. Griffith

A shortened instrument for literacy screening.

The Rapid Estimate of Adult Literacy in Medicine (REALM-R), a new 8-item instrument designed to rapidly screen patients for potential health literacy problems, was administered to 157 patients. The REALM-R was correlated with Wide Range Achievement Test-Revised (WRAT-R) (.64) and demonstrated a Cronbach’s α of 0.91. The REALM-R identified 26 of 30 persons scoring more than 1 standard deviation below the mean on the WRAT-R, corresponding to a sixth grade reading level. The REALM-R identified a substantial number of people who scored poorly on the WRAT-R, and depending on further studies of validity and reliability, may offer a practical approach to identify patients at risk for health literacy problems in a clinical setting.

House Staff Nonverbal Communication Skills and Standardized Patient Satisfaction

OBJECTIVE: To examine the association of physician nonverbal communication with standardized patient (SP) satisfaction in the context of the “quality” of the interview (i.e., information provided and collected, communication skills).DESIGN: Observational.SETTING: One university-based internal medicine residency program.PARTICIPANTS: Fifty-nine internal medicine residents.INTERVIEWING: The 59 residents were recruited to participate in 3 SP encounters. The scenarios included: 1) a straightforward, primarily “medical” problem (chest pain); 2) a patient with more psychosocial overlay (a depressed patient with a history of sexual abuse); and 3) a counseling encounter (HIV risk factor reduction counseling). Trained SPs rated physician nonverbal behaviors (body lean, open versus closed body posture, eye contact, smiling, tone of voice, nod, facial expressivity) in the 3 encounters. Multiple regression approaches were used to investigate the association of physician nonverbal behavior with patient satisfaction in the context of the “quality” of the interview (SP checklist performance, measures of verbal communication skills), controlling for physician characteristics (gender, postgraduate year).RESULTS: Nonverbal communication skills was an independent predictor of standardized patient satisfaction for all 3 patient stations. The effect sizes were substantial, with nonverbal communication predicting 32% of the variance in patient satisfaction for the chest pain station, 23% of the variance for the depression-sexual abuse station, and 19% of the variance for the HIV counseling station.CONCLUSION: Better nonverbal communication skills are associated with significantly greater patient satisfaction in a variety of different types of clinical encounters with standardized patients. Formal instruction in nonverbal communication may be an important addition to residency.

The Loss of Student Idealism in the 3rd-Year Clinical Clerkships.

The purpose of this study was to specify how student attitudes toward different types of patients and the profession change during clinical rotations. A questionnaire was given to all medical students prior to 3rd-year rotations regarding their attitudes toward the medical profession and patient types. It was given again after students completed their l6-week medicine-surgery clerkship. Eighty-eight of 96 students responded to preand posttests. Students became less idealistic toward two patient groups: the elderly and people with chronic pain. After clerkship, students believed a greater percentage of the elderly were demented (26% increasing to 35%, p = .09 and that a greater percentage of patients with chronic pain are drug seekers (l5% increasing to 24%, p = .004). The authors conclude that in the 3rd year of medical school students become less idealistic toward elderly patients, those with chronic pain, and the profession.

Self- and Peer Assessment in a First-Year Communication and Interviewing Course

Peer and self-evaluation are crucial in the professional development of physicians. However, these skills must be learned, and there are barriers to their acceptance and successful utilization. To overcome these obstacles, it has been suggested that these concepts should be addressed longitudinally throughout medical education. Therefore, first-year medical students were introduced to peer and self-assessment as part of a videotape review during an interviewing course by having students complete written peer and self-assessments of the interviews. Students’self-assessments were compared with the assessments of peers and faculty. Written evaluations showed peers were more lenient than faculty and students were most critical of their own performances. Students could provide balanced assessments of their peers but were predominately negative regarding their own performances. It appears first-year students are capable of evaluating their peers but have difficulty accurately assessing their own performance. Further interventions are needed to foster self-assessment skills in first-year students.

Improving Students’ Sexual History Inquiry and HIV Counseling with an Interactive Workshop Using Standardized Patients

Sexual history and HIV counseling are essential clinical skills. Our project’s purpose was to evaluate a standardized patient (SP) educational intervention teaching third-year medical students sexual history taking and HIV counseling. A 4-hour SP workshop was delivered to one-half of the class. Four weeks later, all students engaged in an SP examination including one station on assessing sexual history taking and HIV counseling. Workshop participants scored one standard deviation higher on sexual history and HIV counseling items than nonparticipants. Our sexual history and HIV counseling curriculum was associated with students asking more thorough sexual histories and providing more HIV counseling.

The Loss of Idealism Throughout Internship

The purpose of this project was to understand how resident attitudes to specific types of patients change throughout their internship. Over a 3-year period all 1st-year internal medicine residents were asked to complete a 15-item survey regarding their attitudes toward certain patient types and the profession. The survey was administered the 1st day of the internship, again in mid-November, and in June in the last month of internship. Sixty-one of 80 interns (76% response) completed all three administrations of the survey. In general, there were statistically significant differences in attitudes from the first administration to the second in all categories (all changes reflecting less idealism), with attitudes remaining the same for the second to third administration. For example, interns believed significantly more patients requesting narcotics were drug seekers (19% vs. 33%/ 37%, p < .0001) and a lesser percentage of the elderly could care for themselves independently(62% vs. 50%/48%, p < .0001). We conclude interns become less idealistic toward patients and the profession throughout internship, with the greatest change within the first 5 months.

Communication and decision making about life-sustaining treatment: examining the experiences of resident physicians and seriously-ill hospitalized patients.

BACKGROUNDDespite evidence-based recommendations for communication and decision making about life-sustaining treatment, resident physicians’ actual practice may vary. Few prior studies have examined these conversations qualitatively to uncover why ineffective communication styles may persist. OBJECTIVETo explore how discussions about life-sustaining treatment occur and examine the factors that influence physicians’ communicative practices in hopes of providing novel insight into how these processes can be improved.PARTICIPANTS AND APPROACHWe conducted and recorded 56 qualitative semi-structured interviews with participants from 28 matched dyads of a resident physician and a hospitalized patient or their surrogate decision maker with whom cardiopulmonary resuscitation was discussed. Transcripts were analyzed and coded using the constant comparative method to develop themes.MAIN RESULTSResident physicians introduced decisions about resuscitation in a scripted, depersonalized and procedure-focused manner. Decision makers exhibited a poor understanding of the decision they were being asked to make and resident physicians often disagreed with the decision. Residents did not advocate for a particular course of action; however, the discussions of resuscitation were framed in ways that may have implicitly influenced decision making.CONCLUSIONSResidents’ communication practices may stem from their attempt to balance an informed choice model of decision making with their interest in providing appropriate care for the patient. Physicians’ beliefs about mandatory autonomy may be an impediment to improving communication about patients’ choices for life-sustaining treatment. Redefining the role of the physician will be necessary if a shared decision making model is to be adopted.

Relationships of how well attending physicians teach to their students' performances and residency choices.

No abstract available.

Six-year documentation of the association between excellent clinical teaching and improved students' examination performances.

With increasing fiscal pressures on academic medical centers, many institutions are moving towards mission-based financing, the notion that the clinical, research, and teaching missions must no longer depend upon cross-subsidization but must financially support themselves. With this increased mission-specific accountability, there will be greater emphasis on measurable outcomes to justify the costs associated with the mission. In the realm of clinical teaching, the literature is replete with studies of qualities of excellent teachers, studies of how to measure teaching, and studies demonstrating that faculty development in teaching can influence clinical teachers’ self-reported behaviors, actual behaviors, and teaching ratings. However, for the most part, the fundamental outcome of teaching has been left unstudied: that is, does the quality of teaching actually influence student learning? Although this may seem a truism too obvious for investigation, despite the cherished belief of clinical teachers there is very little quantitative evidence that better teaching is associated with enhanced student learning. We recently reported the first documentation of the association of students’ learning with the relative teaching abilities of attending physicians and residents. In these studies of students and their clinical teachers over the academic years 1993–1995, we found that medical students who worked on their internal medicine or surgical clinical clerkships with our best clinical teachers scored significantly higher on post-clerkship examinations and even on the U.S. Medical Licensing Examination (USMLE) Step 2. Our findings have been replicated at the University of Michigan. The only other study noting an association of teaching with learning, published in 1983, involved high school students in a remedial math class. To our knowledge, this is the extent of the quantitative evidence in all the educational literature that better teaching is associated with better learning. Our previous reports, however, had several limitations. For one, our measure of teaching ‘‘quality’’ was based only on students’ ratings. One can argue (as we did in those articles) that the learners are the best judges of the learning climate. Even though we controlled in our analysis for prior student academic achievement (USMLE Step 1 scores), it was possible that students especially excited about internal medicine scored better on internal medicine examinations and, in their enthusiasm, rated their instructors higher, with a spurious association of examination performance and teaching rating. Second, though statistically significant, our effect sizes were modest, amounting to one-sixth to one-seventh of a standard deviation on a test, or, for example, three points on the USMLE Step 2. Third, these studies encompassed only two academic years, and a limited number of teachers and students. Because this sample was small, we included in the analysis all teachers regardless of the numbers of students they worked with, even those with few teaching ratings. Though we were gratified to demonstrate an association between teaching and learning, our results may have been attenuated by the small sample and the inclusion of in the analysis of all teachers, regardless of numbers of teaching evaluations (teachers with imprecise measures of their teaching ability). Therefore, the purpose of this project was to refine the method of our previous studies by using a larger sample of students and attending physicians, more precise measures of teaching ability, and a way of disentangling the potential confounders of raters and teachers. Our formal hypothesis was that students who are exposed to our highest-rated attending physicians during their internal medicine clerkship will score better on end-of-clerkship examinations and on the USMLE Step 2.

Domestic violence: increasing knowledge and improving skills with a four-hour workshop using standardized patients

Purpose. Domestic violence (DV) is common, yet physicians feel unprepared to address it. Educational interventions may improve the care provided to DV victims, yet the effectiveness of interventions is often unproven. Method. Written questions and DV-specific standardized patient (SP) checklist items from an end-of-clerkship and fourth-year comprehensive multispecialty (the Clinical Performance Examination or CPX) examinations of medical students participating in a DV workshop using SPs was compared with nonparticipants. Results. DV workshop participants’ and nonparticipants’ written question mean scores were 93.2% and 85.8%, respectively, p = .02. End-of-clerkship SP examination DV-specific checklist scores for participants and nonparticipants was 76.3% and 60.0%, respectively, p = .002. Workshop participants scored 44.1% on the CPX DV-specific checklist items versus 35.6% for the nonparticipants, p = .01. Conclusion. A DV workshop improved knowledge and skills assessed four and an average of 27 weeks later.