Dianne Wagner

Not the same everywhere: Patient-centered learning environments at nine medical schools

BACKGROUND: Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the “hidden curriculum.” However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools.OBJECTIVE: To examine patient-centered characteristics of learning environments at 9 U.S. medical schools.DESIGN: Cross-sectional internet-based survey.PARTICIPANTS: Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003.MEASUREMENTS: We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school’s environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students’ experiences, and support for students’ patient-centered behaviors), and is designed to measure these areas independent of respondents’ attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents.RESULTS: The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school.CONCLUSIONS: The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

The patient safety OSCE for PGY-1 residents: a centralized response to the challenge of culture change.

Background: Accreditation and Institute of Medicine mandates require retooling of graduate medical education curriculum and assessment processes. This Objective Structured Clinical Exam (OSCE) focused on patient safety-specific skills important to stakeholders from multiple institutions. Purposes: A 10-station OSCE was designed to assess patient safety-related competencies in new Postgraduate Year 1 (PGY-1) residents. The OSCE emphasized performance of essential skills and teamwork, and it provided early formative feedback to trainees and leadership. Methods: Group nominal process selected 10 final OSCE stations. Two stations were designed to assess team competencies and response to feedback. Two hundred thirty-five trainees enrolled in 64 programs participated during summer 2006. Skill-set aggregation was employed to improve the validity of individual feedback. Results: Significant performance deficits were noted. Trainee and administrator evaluation of the experience was positive. Conclusions: Multi-institutional test development and centralized testing was well received and produced worrisome results. Early assessment can guide the development of task-specific personalized learning plans and systemwide curricular improvement. Further research is needed to determine whether such an effort directed at PGY-1 trainees can improve trainee performance and patient safety.

Documenting clinical performance problems among medical students: feedback for learner remediation and curriculum enhancement

Introduction We operationalized the taxonomy developed by Hauer and colleagues describing common clinical performance problems. Faculty raters pilot tested the resulting worksheet by observing recordings of problematic simulated clinical encounters involving third-year medical students. This approach provided a framework for structured feedback to guide learner improvement and curricular enhancement. Methods Eighty-two problematic clinical encounters from M3 students who failed their clinical competency examination were independently rated by paired clinical faculty members to identify common problems related to the medical interview, physical examination, and professionalism. Results Eleven out of 26 target performance problems were present in 25% or more encounters. Overall, 37% had unsatisfactory medical interviews, with ‘inadequate history to rule out other diagnoses’ most prevalent (60%). Seventy percent failed because of physical examination deficiencies, with missing elements (69%) and inadequate data gathering (69%) most common. One-third of the students did not introduce themselves to their patients. Among students failing based on standardized patient (SP) ratings, 93% also failed to demonstrate competency based on the faculty ratings. Conclusions Our review form allowed clinical faculty to validate pass/fail decisions based on standardized patient ratings. Detailed information about performance problems contributes to learner feedback and curricular enhancement to guide remediation planning and faculty development.

What are the implications of implementation science for medical education

Background Derived from multiple disciplines and established in industries outside of medicine, Implementation Science (IS) seeks to move evidence-based approaches into widespread use to enable improved outcomes to be realized as quickly as possible by as many as possible. Methods This review highlights selected IS theories and models, chosen based on the experience of the authors, that could be used to plan and deliver medical education activities to help learners better implement and sustain new knowledge and skills in their work settings. Results IS models, theories and approaches can help medical educators promote and determine their success in achieving desired learner outcomes. We discuss the importance of incorporating IS into the training of individuals, teams, and organizations, and employing IS across the medical education continuum. Challenges and specific strategies for the application of IS in educational settings are also discussed. Conclusions Utilizing IS in medical education can help us better achieve changes in competence, performance, and patient outcomes. IS should be incorporated into curricula across disciplines and across the continuum of medical education to facilitate implementation of learning. Educators should start by selecting, applying, and evaluating the teaching and patient care impact one or two IS strategies in their work.Background Derived from multiple disciplines and established in industries outside of medicine, Implementation Science (IS) seeks to move evidence-based approaches into widespread use to enable improved outcomes to be realized as quickly as possible by as many as possible. Methods This review highlights selected IS theories and models, chosen based on the experience of the authors, that could be used to plan and deliver medical education activities to help learners better implement and sustain new knowledge and skills in their work settings. Results IS models, theories and approaches can help medical educators promote and determine their success in achieving desired learner outcomes. We discuss the importance of incorporating IS into the training of individuals, teams, and organizations, and employing IS across the medical education continuum. Challenges and specific strategies for the application of IS in educational settings are also discussed. Conclusions Utilizing IS in medical education can help us better achieve changes in competence, performance, and patient outcomes. IS should be incorporated into curricula across disciplines and across the continuum of medical education to facilitate implementation of learning. Educators should start by selecting, applying, and evaluating the teaching and patient care impact one or two IS strategies in their work.

A repurposed tool: the Programme Evaluation SOAP Note

Medical Education 2010: 44 : 298–305

An OSCE remediation experience focused on diagnostic reasoning.

Norcini et al. (2011) are to be congratulated for putting together an excellent summary of the state-of-the-art in medical education assessment. If there is anything missing in their summary, then it is in the field of cost. They mention costs but only twice and only briefly – as a feature of feasibility that is important to both examinees who are paying to sit and governments who are paying to set (cost unsurprisingly is important to those who foot the bill). We know an increasing amount about what constitutes a high-quality assessment – for example, to mention just two features, the need to use multiple methods in assessment and multiple occasions to assess. However, we know less about cost in assessment. According to government figures, the UK spends £4.8 billion annually on healthcare professional education but we do not know how much of that is spent on assessment. Nor do we know what constitutes value in assessment – that is, higher quality in assessment at lower costs. We do however know that there are likely to be cost inefficiencies in certain exams. Let us look at Objective Structured Clinical Examinations (OSCEs): a common error in setting OSCEs is to have two examiners per station (Schuwirth & van der Vlueten 2010). Two examiners per station seems sensible but ‘‘the added value of the second in terms of reliability is quite limited’’ (Schuwirth & van der Vlueten 2010). So it adds a small amount to the value but doubles the cost of supplying examiners. This is likely to be the case but there are no evaluation studies that look at cost and value that can definitively prove it. Has the time for such studies now come? Should we also abandon the term feasibility and replace it with cost. Surely, everything is feasible in this context if you have sufficient funding?

Better data for teachers, better data for learners, better patient care: College-wide assessment at Michigan State University's college of human medicine

Abstract When our school organized the curriculum around a core set of medical student competencies in 2004, it was clear that more numerous and more varied student assessments were needed. To oversee a systematic approach to the assessment of medical student competencies, the Office of College-wide Assessment was established, led by the Associate Dean of College-wide Assessment. The mission of the Office is to ‘facilitate the development of a seamless assessment system that drives a nimble, competency-based curriculum across the spectrum of our educational enterprise.’ The Associate Dean coordinates educational initiatives, developing partnerships to solve common problems, and enhancing synergy within the College. The Office also works to establish data collection and feedback loops to guide rational intervention and continuous curricular improvement. Aside from feedback, implementing a systems approach to assessment provides a means for identifying performance gaps, promotes continuity from undergraduate medical education to practice, and offers a rationale for some assessments to be located outside of courses and clerkships. Assessment system design, data analysis, and feedback require leadership, a cooperative faculty team with medical education expertise, and institutional support. The guiding principle is ‘Better Data for Teachers, Better Data for Learners, Better Patient Care.’ Better data empowers faculty to become change agents, learners to create evidence-based improvement plans and increases accountability to our most important stakeholders, our patients.

Progress testing 2.0: clinical skills meets necessary science

Introduction Progress testing has been widely used in medical schools to test scientific knowledge but has not been reported for assessing clinical skills. Development We designed a novel progress examination that included assessments of both clinical performance and underlying basic and social science knowledge. This Progress Clinical Skills Examination (PCSE) was given to 21 early medical students at the beginning and end of a 6-week pilot test of a new medical school curriculum. Implementation This examination was feasible for early students, easy to map to curricular objectives, and easy to grade using a combination of assessment strategies. Future directions Use of a PCSE is feasible for early medical students. As medical schools integrate clinical experience with underlying knowledge, this type of examination holds promise. Further data are needed to validate this examination as an accurate measure of clinical performance and knowledge.

Expanding the objective structured clinical examination (OSCE) to teach documentation, coding and billing.

13 Research is an important part of clinicians’ work. However, I have gained the impression that successful researchers are sometimes valued over enthusiastic clinical teachers. Research success is easy to quantify whereas teaching quality may be not, particularly not objectively (Katarey 2012). This per se holds true, but that is where students again come into play. Courses are evaluated regularly, and who is better to judge a teacher’s performance than participating students? I, therefore, propose that universities should systematically identify qualified educators – based in part on student evaluations – and support this important clinical sub-population with the same resources as research staff. And, what enables clinical teachers to be good at their craft? In this student’s opinion, it is as Steve Jobs once put it, ‘‘The only way to do great work is to love what you do’’ (Stanford News Service 2005).

Safety science meets basic science in problem-based learning

linking cell biology to anatomy and physiology. Why the idea was necessary Students learning histology at our medical school have increased in number recently and it has become difficult to provide personal microscope time for them. In 2000 we instigated an in-house, computer-based system of histology teaching for practical classes. This was well received by students and staff, but now appears rather tired as it is a relatively static programme with little interactivity. What was done We have recently introduced a new, highly interactive, web-based digital microscope system for the viewing of histological images. This system, which we call UCL SlideSurfer, utilises very high-quality scanned images of our best microscope slides which can be viewed on class computers or online at home. This hardware and software package provides the element of real-time, dynamic microscopy and offers students a truly innovative experience in a manner analogous to that of Google Earth; they can view a tissue section on screen at a very low magnification and then zoom in on any region at progressively increasing magnifications, right down to single cells and nuclei at exceptionally high resolution. Students are led to important structures by a series of annotations on each ‘slide’, but are free to explore any part of the tissue. For this project, our extensive microscope slide collection covering the entire range of body tissues was systematically analysed and approximately 100 of the best-quality slides were chosen and dispatched to a professional provider of digital solutions, where they were scanned at very high resolution and uploaded to a website. When the quality of each scanned slide had been checked, text and questions were applied. Evaluation of results and impact Staff have found that SlideSurfer has stimulated students into learning histology. Student feedback has been exceptional; comments include: ‘I particularly like the software that is used within these practicals and I found SlideSurfer a very useful tool in helping me to cover all of the objectives’; ‘This is a fantastic way of teaching histology – the software [SlideSurfer] is brilliant’; ‘Really enjoyed using SlideSurfer and particularly the fact that we can access all the histology information from outside the labs’, and ‘Enjoyed the interactivity; maybe we could do more of that?’ Students liked having access to what is, in effect, a digital microscope with a box of our best slides at home or anywhere they have Internet access. We believe this is an innovative, engaging and effective method for teaching histology. Correspondence: G Campbell, Department of Cell and Developmental Biology, University College London, Gower Street, London WC1E 6BT, UK. Tel: 00 44 207 679 7764; Fax: 00 44 207 679 7349; E-mail: g.campbell@ucl.ac.uk