David W. Rudy

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.

A pilot study assessing the influences of charge data and group process on diagnostic test ordering by residents.

Purpose Providing charge data to resident physicians has been shown to reduce the amounts spent on diagnostic testing. This pilot study sought to determine the influences of charge data and group decision making on diagnostic test ordering by internal medicine residents. Method In an interactive workshop, 23 internal medicine residents received a hypothetical case. They completed an 18-item questionnaire estimating charges for diagnostic tests and then “ordered” tests. The residents were then randomly divided into groups that either received charge data, received charge data after ordering tests, or received no charge data. The groups ordered tests by consensus. Tests were weighted for appropriateness (+1 to +6) and inappropriateness (−1 to −6). Analyses compared individual and group decisions and effect of availability of charge data. Results Residents with access to charge data spent less on tests, but also had lower appropriateness scores. The appropriateness of the diagnostic workup was better by groups than by individuals, but cost more. Conclusion Cost-containment interventions targeted towards doctors in training need to address the effect on quality of care and the influence of the group process in clinical decision making. Group diagnostic decisions may be more costly, but more appropriate.

Student involvement on teaching rounds.

Background Inpatient internal medicine education occurs in a fragile learning environment. The authors hypothesized that when medical students are involved in teaching rounds, residents may perceive a decrease in value of attending teaching. Method During two summer periods, trained research assistants shadowed teaching rounds, tracking patient census and team call status, recording basic content of rounds, and delivering a survey instrument to the learners, asking them to rate the quality of the attending’s teaching that day. Results One hundred sixty-six rounds were analyzed. Attending teaching ratings peaked when students were highly involved. In fact, high student involvement was an independent predictor of higher resident evaluation of teaching rounds (P < .0001). Conclusions The best teaching occurred when involvement of medical students was greatest and their involvement was not necessarily a zero-sum game. The authors conclude that attending investment in medical student education during teaching rounds benefits all members of the inpatient team.

Hypertension update, JNC8 and beyond

Hypertension is the most preventable major risk factor for cardiovascular morbidity and mortality. The etiology of elevated blood pressure is a complex process involving the interaction of genetics, demographics, comorbid disorders, and environmental influences. Effective hypertensive therapy has been shown to reduce cardiovascular morbidity and mortality. JNC reports have served as a valuable source of guidelines, and JNC 8 is the most recently updated guideline for the prevention, diagnosis, and treatment of hypertension. It includes modification of JNC 7 regarding the threshold for therapy, therapeutic goals, and medications or combinations of medications that differ in benefits for certain patient populations. However, JNC 8 generated a significant degree of controversy. This review will evaluate JNC 7 versus JNC 8 guidelines and discuss the most controversial aspects of JNC 8 through a therapeutic perspective. This review will also discuss the most recently available evidence that has an impact on the JNC 8 recommendations. Despite the nuance of clinical guidelines, blood pressure control rates remains suboptimal. We will explore potential reasons and solutions for this dilemma including pharmacogenomics, novel risk-stratification strategies, lifestyle interventions, and integrative care.

Preventing Curriculum Drift: Sustaining Change and Building upon Innovation

Although the curricula of medical schools in the US have generally kept pace with advances in biomedical knowledge and technology, there have been repeated calls from the public to address psychosocial, interpersonal, and professional issues in the training of physicians. Accreditors have called for changes in pedagogy to incorporate active learning and better integrate basic and clinical sciences. Medical educators have responded with curricular reforms, but many innovations are short-lived. In a process we refer to as curricular drift, the curriculum often insidiously returns to its pre-innovative state. While drift implies forces randomly affecting direction, we contend that such drift is inevitable and predictable. Understanding the forces promoting curricular drift may lead to the development of strategies to prevent it. The authors review the case of the University of Kentucky College of Medicine, which has undergone recurring curricular change, and discuss the causes and strategies for overcoming curricular drift.

Radiation-induced breast cancer: the question of early breast cancer screening in Hodgkin's lymphoma survivors

Chest irradiation is associated with numerous early and late complications that arise from ionizing radiation-induced damage to cellular structures within the field of therapy. In patients exposed to chest irradiation at an early age as part of the treatment of childhood cancer, specifically Hodgkins lymphoma, the increased risk of breast cancer in the long run should be considered. A case of a 35-year-old woman who exposed to chest irradiation as part of the treatment of Hodgkins lymphoma at the age of 20 years is presented here and serves as a reminder of this somewhat overlooked complication. The article presents the evidence available for and against breast cancer screening in this particular patient population.

Risking Life and Limb: A Case of Spontaneous Diabetic Muscle Infarction (Diabetic Myonecrosis).

Diabetic muscle infarction, also known as diabetic myonecrosis, is a microvascular complication of poorly controlled diabetes mellitus characterized by unilateral limb pain and swelling. Because these symptoms closely mimic cellulitis and thromboembolism, diagnosis is often delayed or missed altogether, leading to increased morbidity and inappropriate treatment. We describe a case of unilateral limb pain and swelling due to diabetic muscle infarction in a 36-year-old patient with poorly controlled diabetes mellitus. We also review the literature on the diagnosis, prognosis, and management of this under-recognized condition.

353 SEEING THE "BIG " PICTURE: FIRST-YEAR MEDICAL STUDENTS' PERCEPTIONS OF COMMUNITY-BASED RESOURCES, BARRIERS, AND POTENTIAL SOLUTIONS TO THE OBESITY EPIDEMIC.

Purpose In addition to addressing issues with individuals, physicians need to understand community resources as well as barriers and potential solutions in order to effectively intervene in health behavioral issues. The purpose of our study was to determine how well first-year medical students understand these community issues after an early clinical experience. Methods Following a week-long community-based primary care experience, 103 first-year medical students were asked to write their responses to the following questions: What was the most important health-related behavioral issue leading to illness you observed? What barriers exist in the community to changing this behavior and how may these be overcome? Two raters independently examined responses for themes using qualitative methodology. Results Obesity-related issues (48%) were the most prevalent reported, followed by smoking (39%). We chose to further analyze the data regarding obesity. Student-perceived community barriers included nutritional issues (51%) and accessibility to exercise areas/programs (9%). Twenty-four percent of student responses pertained to individual behavior such as lack of time and sedentary lifestyle rather than community issues. Potential solutions included education (33%), healthy food alternatives (27%), and community-based exercise areas/programs (26%). Conclusions Students had a fairly good grasp of community barriers regarding obesity; however, they did not demonstrate an adequate knowledge of potential community-based solutions. Their main focus was on education rather than on development of community programs or collaborating with existing organizations such as schools, the workplace, or the state. Early teaching in areas of practice-based learning and systems-based practice may be useful in correcting this discrepancy.