Elizabeth Kachur

A Randomized Trial of Teaching Clinical Skills Using Virtual and Live Standardized Patients

AbstractBACKGROUND: We developed computer-based virtual patient (VP) cases to complement an interactive continuing medical education (CME) course that emphasizes skills practice using standardized patients (SP). Virtual patient simulations have the significant advantages of requiring fewer personnel and resources, being accessible at any time, and being highly standardized. Little is known about the educational effectiveness of these new resources. We conducted a randomized trial to assess the educational effectiveness of VPs and SPs in teaching clinical skills. OBJECTIVE: To determine the effectiveness of VP cases when compared with live SP cases in improving clinical skills and knowledge. DESIGN: Randomized trial. PARTICIPANTS: Fifty-five health care providers (registered nurses 45%, physicians 15%, other provider types 40%) who attended a CME program. INTERVENTIONS: Participants were randomized to receive either 4 live cases (n=32) or 2 live and 2 virtual cases (n=23). Other aspects of the course were identical for both groups. RESULTS: Participants in both groups were equivalent with respect to pre-post workshop improvement in comfort level (P=.66) and preparedness to respond (P=.61), to screen (P=.79), and to care (P=.055) for patients using the skills taught. There was no difference in subjective ratings of effectiveness of the VPs and SPs by participants who experienced both (P=.79). Improvement in diagnostic abilities were equivalent in groups who experienced cases either live or virtually. CONCLUSIONS: Improvements in performance and diagnostic ability were equivalent between the groups and participants rated VP and SP cases equally. Including well-designed VPs has a potentially powerful and efficient place in clinical skills training for practicing health care workers.

Assessing changes in intercultural sensitivity among physician trainees using the intercultural development inventory

Abstract Intercultural sensitivity and competence is crucial to a successful medical practice with an increasingly diverse patient population. Twenty-four pediatric resident trainees, 10 American and 14 non-American, at a US medical center, had their intercultural sensitivity assessed, using the intercultural development inventory (IDI), before and after an intercultural training intervention. Demographic measures were taken to assess predictors of intercultural sensitivity. This study expands the use of the IDI to a new population, medical providers, and describes normative standards for this group. A profile emerged which showed low levels of Denial and Defense and moderate levels of Acceptance, Cognitive and Behavioral Adaptation. The Minimization factor was surprisingly high. In spite of small sample size, trends, using IDIs and clinical assessments, indicate that cultural training increased intercultural sensitivity. Discussions focus on the effectiveness of the IDI to measure subtle attitudinal changes and behavioral intentions, the need for multiple intercultural sensitivity measures, and the efficacy of a multi-modal training intervention.

Can professionalism be taught? Encouraging evidence

BACKGROUND Teaching and assessing the Accreditation Council for Graduate Medical Education (ACGME) competencies of Professionalism and Communication have proven to be a challenge for surgical residency training programs. This study used innovative pedagogic approaches and tools in teaching these two competencies. The purpose of this study was to determine whether the learners actually are assimilating and using the concepts and values communicated through this curriculum. METHODS A six-station Objective Structured Clinical Examination (OSCE) was designed using standardized patients to create varying Professionalism and Communication scenarios. The surgical resident learners were evaluated using these OSCEs as a baseline. The faculty then facilitated a specially designed curriculum consisting of six interactive sessions focusing on information gathering, rapport building, patient education, delivering bad news, responding to emotion, and interdisciplinary respect. At the conclusion of this curriculum, the surgical resident learners took the same six-station OSCE to determine if their professionalism and communication skills had improved. RESULTS The surgical resident learners were rated by the standardized patients according to a strict task checklist of criteria at both the precurricular and postcurricular OSCEs. Improvement in the competencies of Professionalism and Communication did achieve statistical significance (P = .029 and P = .011, respectively). CONCLUSIONS This study suggests that the Communication and Professionalism ACGME competencies can be taught to surgical resident learners through a carefully crafted curriculum. Furthermore, these newly learned competencies can affect surgical resident interactions with their patients positively.

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.

Teaching About Substance Abuse with Objective Structured Clinical Exams

BACKGROUND: Although residents commonly manage substance abuse disorders, optimal approaches to teaching these specialized interviewing and intervention skills are unknown.OBJECTIVE: We developed a Substance Abuse Objective Structured Clinical Exam (OSCE) to teach addiction medicine competencies using immediate feedback. In this study we evaluated OSCE performance, examined associations between performance and self-assessed interest and competence in substance abuse, and assessed learning during the OSCE.DESIGN: Five-station OSCE, including different substance abuse disorders and readiness to change stages, administered during postgraduate year-3 ambulatory rotations for 2 years.PARTICIPANTS: One hundred and thirty-one internal and family medicine residents.MEASUREMENTS: Faculty and standardized patients (SPs) assessed residents’ general communication, assessment, management, and global skills using 4-point scales. Residents completed a pre-OSCE survey of experience, interest and competence in substance abuse, and a post-OSCE survey evaluating its educational value. Learning during the OSCE was also assessed by measuring performance improvement from the first to the final OSCE station.RESULTS: Residents performed better (P<.001) in general communication (mean ± SD across stations =3.12±0.35) than assessment (2.65±0.32) or management (2.58±0.44), and overall ratings were lowest in the contemplative alcohol abuse station (2.50±0.83). Performance was not associated with residents’ self-assessed interest or competence. Perceived educational value of the OSCE was high, and feedback improved subsequent performance.CONCLUSIONS: Although internal and family medicine residents require additional training in specialized substance abuse skills, immediate feedback provided during an OSCE helped teach needed skills for assessing and managing substance abuse disorders.

''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.

Two Decades of Title VII Support of a Primary Care Residency: Process and Outcomes

Purpose To assess 23 years of Health Resources and Services Administration (HRSA) Title VII Training in Primary Care Medicine and Dentistry funding to the New York University School of Medicine/Bellevue Primary Care Internal Medicine Residency Program. The program, begun in 1983 within a traditional, inner-city, subspecialty-oriented internal medicine program, evolved into a crucible of systematic innovation, catalyzed and made feasible by initiatives funded by the HRSA. The curriculum stressed three pillars of generalism: psychosocial medicine, clinical epidemiology, and health policy. It developed tight, objectives-driven, effective, nonmedical specialty blocks and five weekly primary care activities that created a paradigm-driven, community-based, role-modeling matrix. Innovation was built in. Every block and activity was evaluated immediately and in an annual, program-wide retreat. Evaluation evolved from behavioral checklists of taped interviews to performance-based, systematic, annual objective structured clinical examinations. Method The authors reviewed eight grant proposals, project reports, and curriculum and program evaluations. They also quantitatively and qualitatively surveyed the 122 reachable graduates from the first 20 graduating classes of the program. Results Analysis of program documents revealed recurring emphases on the use of proven educational models, strategic innovation, and assessment and evaluation to design and refine the program. There were 104 respondents (85%) to the survey. A total of 87% of the graduates practice as primary care physicians, 83% teach, and 90% work with the underserved; 54% do research, 36% actively advocate on health issues for their patients, programs, and other constituencies, and 30% publish. Graduates cited work in the community and faculty excitement and energy as essential elements of the programs impact; overall, graduates reported high personal and career satisfaction and low burnout. Conclusions With HRSA support, a focused, innovative program evolved which has already met each of the six recommendations for future innovation of the Alliance for Academic Internal Medicine Education Redesign Task Force. This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Medical training in school-based health centers: a collaboration among five medical schools.

School-based health centers (SBHCs) have tremendous untapped potential as models for learning about systems-based care of vulnerable children. SBHCs aim to provide comprehensive, community-based primary health care to primary and secondary schoolchildren who might not otherwise have ready access to that care. The staffing at SBHCs is multidisciplinary, including various combinations of nurse practitioners, physicians, dentists, nutritionists, and mental health providers. Although this unique environment provides obvious advantages to children and their families, medical students and residents receive little or no preparation for this type of practice. To address these deficiencies in medical education, five downstate New York state medical schools, funded by the New York State Department of Health, collaborated to define, develop, implement, and evaluate curricula that expose health professions students and residents to SBHCs. The schools identified core competencies and developed a comprehensive training model for the project, including clinical experiences, didactic sessions, and community service opportunities, and they developed goals, objectives, and learning materials for each competency for all types and levels of learners. Each school has implemented a wide range of learning activities based on the competencies. In this paper, the authors describe the development of the collaboration and illustrate the process undertaken to implement new curricula, including considerations made to address institutional needs, curricula development, and incorporation into existing curricula. In addition, they discuss the lessons learned from conducting this collaborative effort among medical schools, with the goal of providing guidance to establish effective cross-disciplinary curricula that address newly defined competencies.

EditorialCultural competence is everyone's responsibility!

Over the past several years, the importance of culture in medical care and medical education has gradually been acknowledged. Increases in literature (e.g. Hall et al., 2004; McLean, 2004; Rosen et al., 2004), healthcare and educational policy recommendations (e.g. Institute of Medicine, 2002; General Medical Council, 2003; World Federation for Medical Education, 2003), and collections of resources (e.g. American Medical Association, 1999) attest to that. Now medical education must develop programs that span the full spectrum of medical education and ensure appropriate teachers. The latter have the dual role of teaching how to provide culturally competent patient care, as well as working with trainees in a culturally effective fashion. This editorial examines how to integrate culture-related training across the continuum of medical education and explores what competences are required of teachers. The concept of culture reflects the breadth and individuality of experience. People have as many cultures as groups they belong to. Figure 1 lists areas where cultural differences frequently occur in patient–clinician and learner–teacher encounters. There are some parallels between communication skills and cultural competence education although the former is probably several years ahead of the latter in terms of development. For a long time communication skills training was relegated to electives, isolated training events and the dedication of a few. Now that this competence is more generally accepted as essential for effective medical care, such training has become more prominent. Programs are not just in basic education but have also been implemented in postgraduate and continuing professional development (CPD). We know that communication skills are not necessarily maintained over time (Pfeiffer et al., 1998). It is likely that cultural competence also represents a lifelong learning need. As physicians (and teachers) cannot be fully competent if they do not communicate effectively, they cannot be fully competent if they are unable to manage cross-cultural encounters effectively.

Web-based objective structured clinical examination with remote standardized patients and Skype: resident experience.

OBJECTIVE Using Skype and remote standardized patients (RSPs), investigators sought to evaluate user acceptance of a web-based objective structured clinical examination (OSCE) among resident physicians. METHODS After participating in four web-based clinical encounters addressing pain with RSPs, 59 residents from different training programs, disciplines and geographic locations completed a 52-item questionnaire regarding their experience with Skype and RSPs. Open-ended responses were solicited as well. RESULTS The majority of participants (97%) agreed or strongly agreed the web-based format was convenient and a practical learning exercise, and 90% agreed or strongly agreed the format was effective in teaching communication skills. Although 93% agreed or strongly agreed they could communicate easily with RSPs using Skype, 80% preferred traditional face-to-face clinical encounters, and 58% reported technical difficulties during the encounters. Open-ended written responses supported survey results. CONCLUSION Findings from this study expose challenges with technology and human factors, but positive experiences support the continued investigation of web-based OSCEs as a synchronous e-learning initiative for teaching and assessing doctor-patient communication. Such educational programs are valuable but unlikely to replace face-to-face encounters with patients. PRACTICE IMPLICATIONS This web-based OSCE program provides physician learners with additional opportunity to improve doctor-patient communication.