Elizabeth H. Morrison

Teaching empathy to first year medical students: evaluation of an elective literature and medicine course.

BACKGROUND Empathy is critical to the development of professionalism in medical students, and the humanities-particularly literature-have been touted as an effective tool for increasing student empathy. This quantitative/qualitative study was undertaken to assess whether reading and discussing poetry and prose related to patients and doctors could significantly increase medical student empathy and appreciation of the relevance of the humanities for their own professional development. METHOD In 2000-2001, first year students (n=22) volunteered for an eight-session literature and medicine elective and were randomly assigned to either immediate participation in the class or a wait-list group, who participated in the same class 6 months later. Complete pre- and post-intervention data for 16 students from both groups were obtained for two quantitative measures of empathy and an attitudes-toward-the-humanities scale. Students also participated in a qualitative group interview pre- and post-intervention. RESULTS Empathy and attitudes toward the humanities improved significantly (p<0.01) after participation in the class when both groups of students were combined. The scaled treatment effect size was in the moderate range (> or =0.60 standard deviation units) for both measures that had statistically significant pre-to-post changes. Furthermore, student understanding of the patients perspective became more detailed and complex after the intervention. Students were also more likely post-intervention to note ways reading literature could help them cope with training-related stress. CONCLUSION A brief literature-based course can contribute to greater student empathy and appreciation for the value of humanities in medical education.

Residents-as-teachers Training in U.s. Residency Programs and Offices of Graduate Medical Education

Resident physicians provide a substantial proportion of the teaching that medical students and junior residents receive, spending numerous hours every week teaching. As stated in the Graduate Medical Education Core Curriculum of the Association of American Medical Colleges (AAMC), residents’ teaching skills are vitally important, particularly for those residents who teach third-year medical students in the so-called ‘‘core clinical clerkships,’’ which traditionally include internal medicine, pediatrics, obstetrics–gynecology, surgery, psychiatry, and family medicine. Although the residency review committee of only one of these specialties (psychiatry) currently mandates residents’ training in teaching skills, the Liaison Committee on Medical Education (LCME) states that residents should ‘‘participate in teaching [clerkship] students’’ and ‘‘be prepared for their roles as teachers and evaluators.’’ Residency programs vary in their teaching-skills training for residents. Bing-You and Tooker found in a 1993 survey of internal medicine residencies that only 20% offered teaching-skills improvement programs for their residents. In most specialties, no published studies have ever documented how many such residents-as-teachers programs exist. To clarify the prevalence and characteristics of residents-as-teachers curricula in U.S. graduate medical education, a group of investigators collaborating with the AAMC’s Section for Graduate Medical Education surveyed directors of residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), as well as deans and directors of offices of graduate medical education (GME) at LCME-accredited medical schools.

Primary care resident, faculty, and patient views of barriers to cultural competence, and the skills needed to overcome them.

Introduction  Primary care residencies are expected to provide training in cultural competence. However, we have insufficient information about the perceptions of stakeholders actually involved in healthcare (i.e. residents, faculty and patients) regarding commonly encountered cross–cultural barriers and the skills required to overcome them.

Reliability and validity of an objective structured teaching examination for generalist resident teachers.

For more than a decade, medical educators have employed standardized students and objective structured teaching examinations (OSTEs) to evaluate the clinical teaching skills of medical faculty. Recent studies have set more rigorous standards of validity and reliability for these performance-based assessments. Some have begun using OSTEs for resident physicians, whom the Liaison Committee for Medical Education (LCME) and others increasingly recognize as critically important teachers for medical students and peers. OSTEs hold great promise for rapid and rigorous evaluation of clinical teaching skills and of new approaches to teacher training. For resident teachers and clinician–educators, it may require years to accumulate sufficient numbers of ‘‘real life’’ teaching evaluations for reliable teaching assessments. OSTEs can truncate this timeline to produce meaningful, prompt teaching assessments for important decisions such as resident evaluations or faculty promotions. OSTEs also facilitate outcomes-based educational research, as well as program evaluation of novel initiatives to improve teaching skills. A major challenge in OSTE practice lies in developing accurate rating scale or checklist instruments appropriate for carefully assessing teaching performance on OSTE stations. Although earlier research has delineated characteristics of exemplary clinical teachers, it remains a challenge to translate this body of knowledge into sensitive and specific assessment instruments. Educational researchers have developed and studied numerous instruments, some tailored to evaluating residents’ teaching skills. The SFDP-26, a 26-item rating scale based on the seven teaching constructs of the Stanford Faculty Development Program (SFDP), is one of the best-validated rating scales available to evaluate clinical teachers. The emerging OSTE literature has yet to address definitively the issue of selecting between dichotomously scored checklists and multi-point rating scales for best assessment of teaching performance. Research offers clearer support for using standardized students portrayed by senior medical students, who in non-OSTE studies have shown themselves to be capable evaluators of teaching. The related literature on objective structured clinical examinations (OSCEs) sheds light on some of these issues. Senior medical students who act as standardized patient examiners for learners may benefit by improving their own communication skills, suggesting that standardized students may improve their own teaching skills. The OSCE literature manifests more controversy over the choice between checklists and rating scales, with a minority of OSCEs featuring multi-point rating scales, although both formats can be used successfully. The purpose of our study was to develop and assess reliability and validity for an eight-station OSTE with case-specific, behaviorally-anchored rating scales, all developed specifically for resident teachers. This OSTE is the primary outcome measure for Bringing Education & Service Together (BEST), an ongoing randomized, controlled trial of a longitudinal residents-as-teachers curriculum at the University of California, Irvine (UCI). We hypothesized that our OSTE would demonstrate acceptable reliability and validity when used to evaluate generalist residents’ clinical teaching skills before and after a pilot administration of the BEST curriculum. Method

Student perceptions of the one minute preceptor and traditional preceptor models.

Background: The one-minute preceptor (OMP) model was developed to effectively and efficiently teach learners while simultaneously addressing patient needs. This study was conducted to determine if third- and fourth-year medical students prefer the OMP model over the traditional precepting model and what teaching points they needed from the clinical encounters. Methods: Third- and fourth-year students (N = 164) at two medical schools completed a questionnaire and prompts on teaching points in response to viewing two videotaped precepting encounters. Differences between OMP and traditional precepting scores were computed using a factorial repeated measures analysis of co-variance (ANCOVA). Teaching points were coded and counted. Results: Students preferred the OMP precepting model to the traditional teaching model (p = 0.001). While the desired teaching points changed as the case presentation/discussion progressed, students were most interested in learning about the clinical presentation or natural progression of the disease regardless of teaching model used. Conclusions: Students rate the OMP as a more effective model of teaching than the traditional model. The teaching points desired by students change as the case presentation/discussion unfolds. Work carried out at: University of California, San Francisco, Office of Medical Education and University of California, Irvine, Department of Family Medicine

Ratings of Perceived Exertion During Aerobic Exercise in Multiple Sclerosis

OBJECTIVE To compare ratings of perceived exertion (RPEs) during aerobic exercise in people with multiple sclerosis (MS) and control participants. DESIGN Prospective experimental study. SETTING An exercise testing laboratory. PARTICIPANTS Sedentary adults (n=12) with mild MS (Expanded Disability Status Scale score < or = 3) aged 30 to 45 years and sedentary age-matched and sex-matched controls (n=12). INTERVENTIONS All participants underwent a graded aerobic exercise test on a cycle ergometer with breath-by-breath gas measurements and continuous heart rate monitoring. MAIN OUTCOME MEASURES After completing the Modified Fatigue Impact Scale, participants rated their effort sense every 30 seconds during exercise using the modified Borg 10-point scale. RESULTS The 2 study groups showed similar baseline characteristics except for higher fatigue scores in the MS group. There were no significant differences for any fitness measure, including oxygen cost slope (in VO(2) x min(-1) x W(-1)), VO(2), or work rate during exercise. Neither heart rate nor RPE--measured at 25%, 50%, 75%, and 100% of VO(2)peak--differed between groups. CONCLUSIONS Despite greater reported fatigue levels, participants with MS showed similar RPE and physiologic responses to submaximal and maximal exercise compared with controls. In MS, the Borg 10-point scale may help improve evidence-based exercise prescriptions, which otherwise may be limited by fatigue, motor impairment, heat sensitivity, or autonomic dysfunction.

Self-perceived attitudes and skills of cultural competence: a comparison of family medicine and internal medicine residents.

This study surveyed resident perceptions of competent cross-cultural doctor-patient communication as a step toward developing an integrative primary care cross-cultural curriculum. Respondents were 57 first-, second- and third-year residents in family medicine (FM) and internal medicine (IM) who completed a questionnaire assessing cross-cultural attitudes and skills relevant to clinical practice. As a group, residents endorsed the relevance of culturally competent communication to patient care, perceived themselves to be fairly competent in the use of culturally competent communication techniques, used such techniques frequently, and generally found them to be quite helpful. FM residents rated culturally competent communication as significantly more relevant, themselves as more competent, and culturally competent communication techniques as more helpful than did IM residents. Over half the residents in both specialties tended to identify as serious cross-cultural problems those that focused on perceived patient shortcomings.

Attributes of effective community preceptors for pre-clerkship medical students

Background: Attributes of effective precepting of pre-clerkship medical students in community settings are not adequately described. As part of preceptor needs assessment, we conducted site visits over three consecutive years. We also measured the preceptorships’ educational quality, using students’ post-rotation data, to identify priority areas for faculty development, corroborate site visit findings, and assess functions of the site visit. Methods: Three university faculty directly observed teaching encounters in 83 community preceptors’ offices during a 12–18-week second year (pre-clerkship) medical student rotation. Data were collected on practice demographics, teaching content, and educational quality, using multiple measures. Narrative responses to interview questions were coded for prevalent themes. Student post-rotation assessments were obtained by anonymous online evaluations. Results: Good precepting attributes and suggestions for improvement were identified from both narrative analysis and student post-rotation evaluations in these key areas: independence in patient assessment, time spent teaching, giving feedback and orientation to the preceptors practice. Student evaluations of preceptors’ effectiveness significantly improved from year 1 to 2 and persisted into year 3. Appropriate faculty development strategies were derived from the combined results. Conclusions: The site visit by university faculty allows real-time observation and may itself be an effective intervention for improving teaching and learning.

The primary care specialties working together: a model of success in an academic environment.

In todays environment of decreasing resources and increasing competition among clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, if possible, integration. Academic leaders at the University of California, Irvine (UCI), have developed a collaborative model in which faculty in family medicine, general internal medicine, and general pediatrics cooperate extensively in education, research, and patient care. Generalist faculty jointly administer and teach both a four-year “doctoring” curriculum for medical students and an array of integrated curricula for primary care residents, including a communication skills course. Several primary faculty jointly developed a collaborative unit for health policy and research, now an active locus for multidisciplinary research. Other faculty worked together to develop a primary care medical group that serves as a model for interdisciplinary practice at UCI. Recently, the university recruited an associate dean for primary care who leads the new UCI Primary Care Coalition, reflecting and promoting this interspecialty cooperation. This coalition does not represent a step toward a generic primary care specialty; UCIs generalist disciplines have preserved their individual identities and structures. Yet interdisciplinary collaboration has allowed primary care faculty to share educational resources, a research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources while maximizing collective negotiating abilities and mutual success.

The Impact of an Objective Structured Teaching Evaluation on Faculty Teaching Skills

Background: Objective structured teaching evaluations (OSTEs) have been utilized to evaluate educational curricula and for resident and faculty development. Purpose: This study examines the impact of an OSTE on faculty teaching effectiveness and faculty satisfaction. Methods: From 2004 to 2007, 46 faculty members participated in the OSTE. Faculty assessed their teaching abilities with a retrospective pre-post-test analysis. Faculty teaching evaluations for the 6 months before and after the OSTE were compared. Faculty participants completed satisfaction questionnaires regarding their OSTE experience and made teaching plans for the future. Results: After the OSTE, faculty reported statistically significant improvements in all self-assessed teaching skills. There was, however, no improvement in their teaching evaluations. Faculty satisfaction with the OSTE experience was high. They indicated teaching plans incorporating lessons from the OSTE. Conclusions: Faculty felt the OSTE was a rewarding experience and reported improvement in their teaching abilities; however, faculty teaching evaluations did not improve.