David Stevens

Measuring the competence of residents as teachers.

Medical residents, frontline clinical educators, must be competent teachers. Typically, resident teaching competence is not assessed through any other means than gleaning learner’s comments. We developed, evaluated, and integrated into our annual objective structured clinical examination a resident teaching skills assessment using “standardized” students. Faculty observers rated residents using a customized 19-item rating instrument developed to assess teaching competencies that were identified and defined as part of our project. This was feasible, acceptable, and valuable to all 65 residents, 8 students, and 16 faculty who participated. Teaching scenarios have potential as reliable, valid, and practical measures of resident teaching skills.

A randomized trial of a brief multimedia intervention to improve comprehension of food labels.

OBJECTIVE Food label use is associated with better food choices, an essential part of the management of many chronic diseases. Previous studies suggest lack of comprehension of food labels. We studied a multimedia intervention to improve food label comprehension in a sample of low income patients in New York City. METHODS This randomized study took place at Gouverneur Healthcare Services from 2005 until 2007. The intervention group (n=29) received a Nutrition Facts Label pocket card and viewed a video explaining card use. The control group (n=27) received written materials. Participants completed a 12-item pre- and post-intervention nutrition food label quiz. Quiz scores were analyzed using repeated measures analysis of variance. RESULTS The intervention group had greater improvement on the quiz than the control group (p<0.001). There was a three way interaction by time with health literacy and treatment group where the greatest improvement occurred in patients with adequate health literacy in the intervention group (p<0.05). There was no improvement in patients with limited health literacy. CONCLUSION A multimedia intervention is an effective way to improve short-term food label comprehension in patients with adequate health literacy. Further research is necessary to improve understanding of food labels in patients with limited health literacy.

Extended-release naltrexone for treatment of alcohol dependence in primary care

The feasibility of using extended-release injectable naltrexone (XR-NTX) to treat alcohol dependence in routine primary care settings is unknown. An open-label, observational cohort study evaluated 3-month treatment retention, patient satisfaction, and alcohol use among alcohol-dependent patients in two urban public hospital medical clinics. Adults seeking treatment were offered monthly medical management (MM) and three XR-NTX injections (380 mg, intramuscular). Physician-delivered MM emphasized alcohol abstinence, medication effects, and accessing mutual help and counseling resources. Seventy-two alcohol-dependent patients were enrolled; 90% (65 of 72) of eligible subjects received the first XR-NTX injection; 75% (49 of 65) initiating treatment received the second XR-NTX injection; 62% (40 of 65), the third. Among the 56% (n = 40) receiving three injections, median drinks per day decreased from 4.1 (95% confidence interval = 2.9-6) at baseline to 0.5 (0-1.7) during Month 3. Extended-release naltrexone delivered in a primary care MM model appears a feasible and acceptable treatment for alcohol dependence.

Extended-release naltrexone plus medical management alcohol treatment in primary care: findings at 15 months

The feasibility of long-term extended-release naltrexone (XR-NTX) alcohol treatment is unknown. Following an initial 12-week, single-arm, observational trial of XR-NTX plus medical management (MM) in primary care, we offered 48 additional weeks of XR-NTX treatment (12 additional monthly injections) in two public primary care clinics as a naturalistic extension study. Of 65 alcohol dependent adults initiating XR-NTX treatment, 40 (62%) completed the initial 12-week XR-NTX observational trial, and 19 (29%) continued treatment for a median of 38 weeks total (range, 16-72 weeks; median 8 total XR-NTX injections). Among active extension phase participants, self-reported rates of drinking days (vs. last 30 days pre-treatment baseline) were low: median 0.2 vs. 6.0 drinks per day; 82 vs. 38% days abstinent; 11 vs. 61% heavy drinking days. Long-term XR-NTX treatment in a primary care MM model was feasible and may promote lasting drinking reductions or alcohol abstinence (clinical trial: NCT00620750).

''Oh! She Doesn't Speak English!'' Assessing Resident Competence in Managing Linguistic and Cultural Barriers

AbstractBACKGROUND: Residents must master complex skills to care for culturally and linguistically diverse patients. METHODS: As part of an annual 10-station, standardized patient (SP) examination, medical residents interacted with a 50-year-old reserved, Bengali-speaking woman (SP) with a positive fecal occult blood accompanied by her bilingual brother (standardized interpreter (SI)). While the resident addressed the need for a colonoscopy, the SI did not translate word for word unless directed to, questioned medical terms, and was reluctant to tell the SP frightening information. The SP/SI, faculty observers, and the resident assessed the performance. RESULTS: Seventy-six residents participated. Mean faculty ratings (9-point scale) were as follows: overall 6.0, communication 6.0, knowledge 6.3. Mean SP/SI ratings (3.1, range 1.9 to 3.9) correlated with faculty ratings (overall r=.719, communication r=.639, knowledge r=.457, all P<.01). Internal reliability as measured by Cronbach’s α coefficients for the 20 item instrument was 0.91. Poor performance on this station was associated with poor performance on other stations. Eighty-nine percent of residents stated that the educational value was moderate to high. CONCLUSION: We reliably assessed residents communication skills conducting a common clincal task across a significant language barrier. This medical education innovation provides the first steps to measuring interpreter facilitated skills in residency training.

Medical humanities at New York University School of Medicine: an array of rich programs in diverse settings.

The New York University School of Medicine has a rich tradition of cultivating programs in medical humanities and professionalism. They are drawn from the departments, centers, students, and faculty in the School of Medicine, have linkages throughout the university, and are interwoven into the fabric and culture of the institution. Some are centrally based in the School of Medicine’s deans’ office, and others are located in individual departments and receive support from the dean’s office. This article describes representative programs for medical students and faculty. Curricular initiatives, the fundamental components of medical students’ learning, include a course entitled “The Physician, Patient, and Society,” a clerkship essay in the Medicine Clerkship, an opportunity for reflection during the medicine clerkship, and a medical humanities elective. In 2002, the Professionalism Initiative was launched to enhance and reflect the values of the medical profession. Its curriculum consists of a series of events that coordinate, particularly, with existing elements of the first-year curriculum (e.g., orientation week, a session during anatomy, a self-assessment workshop, and a peer-assessment workshop). The Master Scholars Program is a group of five, theme-based master societies consisting of faculty and students who share common interests around the society’s themes. Programs developed for the societies include colloquia, faculty-led seminars, a mandatory student-mentoring program, and visiting scholars. Finally, the authors describe three high-quality literary publications created at New York University School of Medicine. Each of the initiatives undergoes regular critical examination and reflection that drive future planning.

Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system

BackgroundWhile unannounced standardized patients (USPs) have been used to assess physicians’ clinical skills in the ambulatory setting, they can also provide valuable information on patients’ experience of the health care setting beyond the physician encounter. This paper explores the use of USPs as a methodology for evaluating patient-centered care in the health care system.MethodsUSPs were trained to complete a behaviorally-anchored assessment of core dimensions of patient-centered care delivered within the clinical microsystem, including: 1) Medical assistants’ safe practices, quality of care, and responsiveness to patients; 2) ease of clinic navigation; and 3) the patient-centeredness of care provided by the physician. Descriptive data is provided on these three levels of patient-centeredness within the targeted clinical microsystem. Chi-square analyses were used to signal whether variations by teams within the clinical microsystem were likely to be due to chance or might reflect true differences in patient-centeredness of specific teams.ResultsSixty USP visits to 11 Primary Care teams were performed over an eight-month period (mean 5 visits/team; range 2–8). No medical assistants reported detecting an USP during the study period. USPs found the clinic easy to navigate and that teams were functioning well in 60% of visits. In 30% to 47% of visits, the physicians could have been more patient-centered. Medical assistants’ patient safety measures were poor: patient identity was confirmed in only 5% of visits and no USPs observed medical assistants wash their hands. Quality of care was relatively high for vital signs (e.g. blood pressure, weight and height), but low for depression screening, occurring in only 15% of visits. In most visits, medical assistants greeted the patient in a timely fashion but took time to fully explain matters in less than half of the visits and rarely introduced themselves. Physicians tried to help patients navigate the system in 62% of visits.ConclusionsUSP assessment captured actionable, critical, behaviorally-specific information on team and system performance in an urban community clinic. This methodology provides unique insight into the patient-centeredness and quality of care in medical settings.

Electronic Communications with Patients: Improved Safety, Improved Access, or Electronic Leash—Principles and Prospects

Wong and colleagues [1] suggest that Maimonides implies physicians should be available to their patients ‘‘...at all times,’’ via cell phones. That could occasion an editorial of its own about the divine omnipresence called for, the reality that we are not available even to ourselves at all times, and that such dependence seems both impossible and damaging to a patient’s sense of self-efficacy and independence. Their rhetorical device is used to introduce a discussion of cell phones, a recent but certainly not the last medium for doctor–patient communication. The authors touch upon how the core principles of communication are modified by telephonic communication and further so by cell phone use; their comments also pertain to the role of other electronic communications like e-mail, pagers, answering services, intercoms, and devices like electrophysiologic monitors. We propose here to add to the white noise a miasmic semblance of shape that derives from the robust literature about communication in general [2] and telephonic communication in particular [3]. When we are in an age in which many can be reached at most times, when pictures soon will be routinely added to sound, when physiological data will soon be flowing faster than drone videos from Pakistan, we need to think about how to digest all this electronic chyme. Interactive Web sites, electronic social networking, and texting have so altered the way electronically savvy individuals interact that the cell phone call may soon seem as dated as pagers. However, because doctor–patient communication lags in its adoption of new technologies—many doctors do not feel confident assessing patient needs over the phone—we will briefly review the literature on communication skills and its application to telephonic interactions. Much writing about any sort of communications takes the form and stance of the present article: anecdotal, thoughtful but not theoretical, and free of robust scientific evidence about what actually happens, what its effects are, and how it matters to care in an empirical sense. We actually know much worth mastering about doctor–patient communication. There is an emerging consensus model based on over 10,000 articles [4], most relevant to electronic communications and cell phone use, albeit by extrapolation. In brief, whether face-to-face, on the colonoscopy table (before the injection), or on the phone, communications are about gathering information, communicating information, or developing or maintaining a relationship, which includes managing patients’ feelings of dependence, independence (sometimes called activation), a sense of safety, and a sense of autonomy. Skilled A. B. Reisman Department of Medicine, Yale University School of Medicine, New Haven, CT, USA e-mail: Anna.reisman@va.gov

Observing boundaries in conversations with patients.

Suggests to medical students what forms of self-disclosure are acceptable during clinical encounters and when self-disclosure might be interpreted by patients as taking attention away from them. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.