Donna M. Windish

Teaching Medical Students the Important Connection between Communication and Clinical Reasoning

BACKGROUND: Medical students are rarely taught how to integrate communication and clinical reasoning. Not understanding the relation between these skills may lead students to undervalue the connection between psychosocial and biomedical aspects of patient care.OBJECTIVE: To improve medical students’ communication and clinical reasoning and their appreciation of how these skills interrelate in medical practice.DESIGN: In 2003, we conducted a randomized trial of a curricular intervention at Johns Hopkins University School of Medicine. In a 6-week course, participants learned communication and clinical reasoning skills in an integrative fashion using small group exercises with role-play, reflection and feedback through a structured iterative reflective process.PARTICIPANTS: Second-year medical students.MEASUREMENTS: All students interviewed standardized patients who evaluated their communication skills in establishing rapport, data gathering and patient education/counseling on a 5-point scale (1=poor; 5=excellent). We assessed clinical reasoning through the number of correct problems listed and differential diagnoses generated and the Diagnostic Thinking Inventory. Students rated the importance of learning these skills in an integrated fashion.RESULTS: Standardized patients rated curricular students more favorably in establishing rapport (4.1 vs 3.9; P=.05). Curricular participants listed more psychosocial history items on their problem lists (65% of curricular students listing ≥1 item vs 44% of controls; P=.008). Groups did not differ significantly in other communication or clinical reasoning measures. Ninety-five percent of participants rated the integration of these skills as important.CONCLUSIONS: Intervention students performed better in certain communication and clinical reasoning skills. These students recognized the importance of biomedical and psychosocial issues in patient care. Educators may wish to teach the integration of these skills early in medical training.

Cannabinoid Hyperemesis Relieved by Compulsive Bathing

Cannabinoid hyperemesis is a clinical syndrome characterized by repeated vomiting and associated learned compulsive hot water bathing behavior due to long-term marijuana use. Research has indentified type 1 cannabinoid receptors in the intestinal nerve plexus that have an inhibitory effect on gastrointestinal motility. This inhibitory effect may lead to hyperemesis in marijuana users. The thermoregulatory role of endocannabinoids may be responsible for the patients need to take hot showers. We report 2 cases of cannabinoid hyperemesis that demonstrate this unusual adverse effect of marijuana use.

Methodological rigor of quality improvement curricula for physician trainees: a systematic review and recommendations for change.

Purpose To systematically determine whether published quality improvement (QI) curricula for physician trainees adhere to QI guidelines and meet standards for study quality in medical education research. Method The authors searched MEDLINE, EMBASE, CINAHL, and ERIC between 1980 and April 2008 for physician trainee QI curricula and assessed (1) adherence to seven domains containing 35 QI objectives, and (2) study quality using the Medical Education Research Study Quality Instrument (MERSQI). Results Eighteen curricula met eligibility criteria; 5 involved medical students and 13 targeted residents. Three curricula (18%) measured health care outcomes. Attitudes about QI were high, and many behavior and patient-related outcomes showed positive results. Curricula addressed a mean of 4.3 (SD 1.8) QI domains. Student initiatives included 38.2% [95% CI, 12.2%–64.2%] beginning student-level objectives and 23.0% [95% CI, −4.0% to 50.0%] advanced student-level objectives. Resident curricula addressed 42.3% [95% CI, 29.8%–54.8%] beginning resident-level objectives and 33.7% [95% CI, 23.2%–44.1%] advanced resident-level objectives. The mean (SD) total MERSQI score was 9.86 (2.92) with a range of 5 of 14 [total possible range 5–18]; 35% of curricula demonstrated lower study quality (MERSQI score ≤ 7). Curricula varied widely in quality of reporting, teaching strategies, evaluation instruments, and funding obtained. Conclusions Many QI curricula in this study inadequately addressed QI educational objectives and had relatively weak research quality. Educators seeking to improve QI curricula should use recommended curricular and reporting guidelines, stronger methodologic rigor through development and use of validated instruments, available QI resources already present in health care settings, and outside funding opportunities.

Burnout, Coping, and Spirituality Among Internal Medicine Resident Physicians

BACKGROUND Burnout in physicians is common, and studies show a prevalence of 30% to 78%. Identifying constructive coping strategies and personal characteristics that protect residents against burnout may be helpful for reducing errors and improving physician satisfaction. OBJECTIVE We explored the complex relationships between burnout, behaviors, emotional coping, and spirituality among internal medicine and internal medicine-pediatrics residents. METHODS We anonymously surveyed 173 internal medicine and medicine-pediatrics residents to explore burnout, coping, and spiritual attitudes. We used 3 validated survey instruments: the Maslach Burnout Inventory, the Carver Coping Orientation to Problems Experienced (COPE) Inventory, and the Hatch Spiritual Involvement and Beliefs Scale (SIBS). RESULTS A total of 108 (63%) residents participated, with 31 (28%) reporting burnout. Residents who employed strategies of acceptance, active coping, and positive reframing had lower emotional exhaustion and depersonalization (all, P < .03). Residents who reported denial or disengagement had higher emotional exhaustion and depersonalization scores. Personal accomplishment was positively correlated with the SIBS total score (r  =  +.28, P  =  .003), as well as the internal/fluid domain (r  =  +.32, P  =  .001), existential axes (r  =  +.32, P  =  .001), and humility/personal application domain (r  =  +.23, P  =  .02). The humility/personal application domain also was negatively correlated with emotional exhaustion (r  =  -.20, P  =  .04) and depersonalization (r  =  -.25, P  =  .009). No activity or demographic factor affected any burnout domain. CONCLUSIONS Burnout is a heterogeneous syndrome that affects many residents. We identified a range of emotional and spiritual coping strategies that may have protective benefit.

A Clinician‐Educator's Roadmap to Choosing and Interpreting Statistical Tests

As educators seek confirmation of successful trainee achievement, medical education must move toward a more evidence-based approach to teaching and evaluation. Although medical training often provides physicians with a general background in biostatistics, many are not prepared to apply these skills. This can hinder clinician educators as they wish to develop, analyze and disseminate their scholarly work. This paper is intended to be a concise educational tool and guide for choosing and interpreting statistical tests aimed toward medical education assessment. It includes guidelines and examples that clinician-educators can use when analyzing and interpreting studies and when writing methods and results sections of reports.

A ten-month program in curriculum development for medical educators: 16 years of experience.

BACKGROUNDDespite increased demand for new curricula in medical education, most academic medical centers have few faculty with training in curriculum development.OBJECTIVETo describe and evaluate a longitudinal mentored faculty development program in curriculum development.DESIGNA 10-month curriculum development program operating one half-day per week of each academic year from 1987 through 2003. The program was designed to provide participants with the knowledge, attitudes, skills, and experience to design, implement, evaluate, and disseminate curricula in medical education using a 6-step model.PARTICIPANTSOne-hundred thirty-eight faculty and fellows from Johns Hopkins and other institutions and 63 matched nonparticipants.MEASUREMENTSPre- and post-surveys from participants and nonparticipants assessed skills in curriculum development, implementation, and evaluation, as well as enjoyment in curriculum development and evaluation. Participants rated program quality, educational methods, and facilitation in a post-program survey.RESULTSSixty-four curricula were produced addressing gaps in undergraduate, graduate, or postgraduate medical education. At least 54 curricula (84%) were implemented. Participant self-reported skills in curricular development, implementation, and evaluation improved from baseline (p < .0001), whereas no improvement occurred in the comparison group. In multivariable analyses, participants rated their skills and enjoyment at the end of the program significantly higher than nonparticipants (all p < .05). Eighty percent of participants felt that they would use the 6-step model again, and 80% would recommend the program highly to others.CONCLUSIONSThis model for training in curriculum development has long-term sustainability and is associated with participant satisfaction, improvement in self-rated skills, and implementation of curricula on important topics.

Teaching medical students clinical reasoning skills.

To be an effective clinician, a physician must excel at clinical problem solving. Nevertheless, few physicians have been specifically taught clinical reasoning skills during their medical training. This paper describes the format used to teach clinical problem solving to second-year medical students at the University of Connecticut School of Medicine.

Optimal Methods to Screen Men and Women for Intimate Partner Violence: Results From an Internal Medicine Residency Continuity Clinic

Contradictory data exist regarding optimal methods and instruments for intimate partner violence (IPV) screening in primary care settings. The purpose of this study was to determine the optimal method and screening instrument for IPV among men and women in a primary-care resident clinic. We conducted a cross-sectional study at an urban, academic, internal medicine residency continuity clinic in Connecticut among English or Spanish speaking adult patients. One group of patients ( n = 340) received a self-administered questionnaire (SAQ) containing the partner violence screen (PVS) and the Hurt, Insulted, Threatened or Screamed at Questionnaire (HITS). A second group (n = 126) was screened with PVS and HITS by their primary care providers during face-to-face (FTF) clinical encounters. Multivariable logistic regression models were used to determine the association between IPV prevalence and screening method (SAQ or FTF) after adjusting for socio-demographic effects. The overall IPV prevalence was 17.3% using the SAQ and 9.0% with FTF screening (p = .008). Patients receiving the SAQ were more likely to report IPV than those who were screened FTF (adjusted odds ratio [AOR]: 2.6, 95% confidence interval [CI]: 1.2-5.6). This effect persisted for women, who had a higher odds of IPV when screened through a SAQ than when screened FTF (AOR: 3.5, 95% CI: 1.4-8.6). Men did not differ in reporting IPV between methods: 11% with SAQ versus 9.4% FTF (p = .69). In internal medicine residency continuity clinics, a SAQ for IPV may result in higher disclosure and completion rates among female patients compared to FTF screening. Unique screening instruments and methods may be needed for men.

Long‐term follow‐up of a 10‐month programme in curriculum development for medical educators: a cohort study

Context  There is an ongoing need for curriculum development (CD) in medical education. However, only a minority of medical teaching institutions provide faculty development in CD. This study evaluates the long‐term impact of a longitudinal programme in curriculum development.

Correlation of burnout syndrome with specific coping strategies, behaviors, and spiritual attitudes among interns at Yale University, New Haven, USA

Purpose: This study aimed to determine the correlation of burnout syndrome with specific coping strategies, behaviors, and spiritual attitudes among interns in internal medicine, primary care, and internal medicine/pediatrics residency programs at two institutions. Methods: Intern physicians completed anonymous voluntary surveys prior to starting the internship in June 2009 and in the middle of the internship in February 2010. Three validated survey instruments were used to explore burnout, coping, and spiritual attitudes: the Maslach Burnout Inventory, the COPE Inventory, and the Hatch Spiritual Involvement and Beliefs Scale. The interns were in programs at the Yale University School of Medicine and a Yale-affiliated community hospital, New Haven, Connecticut, USA. Results: The prevalence of self-identified burnout prior to starting the internship was 1/66 (1.5%) in June 2009, increasing to 10/53 (18.9%) in February 2010 (P<0.0001). From June 2009 to February 2010, the prevalence of high emotional exhaustion increased from 30/66 (45.5%) to 45/53 (84.9%) (P<0.0001), and that of high depersonalization increased from 42/66 (63.6%) to 45/53 (84.9%) (P=0.01). Interns who employed the strategies of acceptance and active coping were less likely to experience emotional exhaustion and depersonalization (P<0.05). Perceptions of high personal accomplishment was 75.5% and was positively correlated with total scores on the Hatch Spiritual Involvement and Beliefs Scale, as well as the internal/fluid and existential/meditative domains of that instrument. Specific behaviors did not impact burnout. Conclusion: Burnout increased during the intern year. Acceptance, active coping, and spirituality were correlated with less burnout. Specific behaviors were not correlated with burnout domains.