Gail S. Marion

Applying Theory to the Design of Cultural Competency Training for Medical Students: A Case Study.

Although literature suggests that providing culturally sensitive care promotes positive health outcomes for patients, undergraduate medical education currently does not provide adequate cultural competency training. At most schools, cultural competency, as a formal, integrated, and longitudinal thread within the overall curriculum, is still in its infancy. In this article, the authors summarize the current practice of cultural competency training within medical education and describe the design, implementation, and evaluation of a theoretically based, year-long cultural competency training course for second-year students at Wake Forest University School of Medicine. Evaluation of the results indicate that the course was successful in improving knowledge, attitudes, and skills related to cultural competence as well as bringing about positive changes in the medical schools approach to cultural competency training. Also discussed are the implications of the outcomes for the development of culturally competent physicians and how using appropriate theory can help achieve desired outcomes.

Are Medical Students Aware of Their Anti-Obesity Bias?

Purpose Anti-obesity prejudices affect the quality of care obese individuals receive. The authors sought to determine the prevalence of weight-related biases among medical students and whether they were aware of their biases. Method Between 2008 and 2011, the authors asked all third-year medical students at Wake Forest School of Medicine to complete the Weight Implicit Association Test (IAT), a validated measure of implicit preferences for “fat” or “thin” individuals. Students also answered a semantic differential item assessing their explicit weight-related preferences. The authors determined students’ awareness of their biases by examining the correlation between students’ explicit preferences and their IAT scores. Results Of 354 medical students, 310 (88%) completed valid surveys and consented to participate. Overall, 33% (101/310) self-reported a significant (“moderate” or “strong”) explicit anti-fat bias. No students self-reported a significant explicit anti-thin bias. According to the IAT scores, over half of students had a significant implicit weight bias: 39% (121/310) had an anti-fat bias and 17% (52/310) an anti-thin bias. Two-thirds of students (67%, 81/121) were unaware of their implicit anti-fat bias. Only male gender predicted an explicit anti-fat bias (odds ratio 3.0, 95% confidence interval 1.8–5.3). No demographic factors were associated with an implicit anti-fat bias. Students’ explicit and implicit biases were not correlated (Pearson r = 0.03, P = .58). Conclusions Over one-third of medical students had a significant implicit anti-fat bias; few were aware of that bias. Accordingly, medical schools’ obesity curricula should address weight-related biases and their potential impact on care.

Obesity Educational Interventions in U.S. Medical Schools: A Systematic Review and Identified Gaps

Background: Obesity is the second leading cause of preventable death in the United States. However, physicians feel poorly trained to address the obesity epidemic. This article examines effective training methods for overweight and obesity intervention in undergraduate medical education. Using indexing terms related to overweight, obesity, and medical student education, we conducted a literature searched PubMed PsycINFO, Cochrane, and ERIC for relevant articles in English. References from articles identified were also reviewed to located additional articles. Summary: We included all studies that incorporated process or outcome evaluations of obesity educational interventions for U.S. medical students. Of an initial 168 citations, 40 abstracts were retrieved; 11 studies were found to be pertinent to medical student obesity education, but only 5 included intervention and evaluation elements. Quality criteria for inclusion consisted of explicit evaluation of the educational methods used. Data extraction identified participants (e.g., year of medical students), interventions, evaluations, and results. These 5 studies successfully used a variety of teaching methods including hands on training, didactic lectures, role–playing, and standardized patient interaction to increase medical students’ knowledge, attitudes, and skills regarding overweight and obesity intervention. Two studies addressed medical student bias toward overweight and obese patients. No studies addressed health disparities in the epidemiology and bias of obesity. Conclusions: Despite the commonly cited “obesity epidemic,” there are very few published studies that report the effectiveness of medical school obesity educational programs. Gaps still exist within undergraduate medical education including specific training that addresses obesity and long-term studies showing that such training is retained.

Working effectively with interpreters: A model curriculum for physician assistant students

Background: Effective patient-provider communication is crucial to achieving good health care outcomes. To accomplish this with patients of limited English proficiency, learning to work effectively with interpreters is essential. Aims: The primary goal of this study was to determine if physician assistant students could effectively use interpreters to communicate with Spanish speaking patients after implementation of a cultural competency and Medical Spanish curriculum. Method: In year one of a three year implementation process, a module for teaching students to work effectively with interpreters was developed and implemented in the Wake Forest University School of Medicine Department of Physician Assistant Studies. After four hours of orientation, practice and role play, students were observed and recorded during a standardized patient assessment and evaluated by clinicians as well as by trained, bi-lingual evaluators. Results: In the Class of 2007, 94% (43 students) and in the Class of 2008, 96% (47 students) demonstrated competence. Conclusions: Our findings highlight the feasibility and usefulness of training students to work effectively with interpreters. Evaluation and feedback from students and faculty have been positive. Cost for this curriculum enhancement was reasonable, making it feasible to introduce the training into a wide variety of medical and allied health programs.

Extending the Extenders: Compromise for the Geriatric Specialization-Manpower Debate

This pilot study reports on issues germane to the geriatric specialization‐manpower debate. The study found that a large amount of the functional responsibility required by older adults in an urban clinic setting could be delegated to physician extenders. Other findings included shorter hospitalizations, increased feelings of well‐being, and high patient satisfaction with physician extended care. The implications are that rather than develop a new physician specialty, more geriatric manpower needs could be met by delegating responsibility to appropriately trained and supervised physician extenders. J Am Geriatr Soc 33:559, 1985

Physician Assistant Students Take the Plunge

INTRODUCTION The Department of Physician Assistant Studies at Wake Forest University School of Medicine is a graduate-level program that has a history of curricular innovation using clinical problem-based learning (PBL) strategies that emphasize a small-group approach to learning. Graduates of the program complete a 24-month course of study, and one class of 48 students is enrolled in early June each year. In the spring of 2007, just prior to the clinical year for the students in the class of 2008, the Northwest Area Health Education Center assisted the PA faculty in revising the AHEC’s Community Plunge program, developed initially for primary care interns, for PA students. The faculty felt that the Community Plunge experience would enhance the PA program’s current efforts, which include digitally delivered PowerPoint cases and master’s projects, by providing direct interaction with various community organizations that serve the diverse needs of our community and its members. Such exposure can stimulate ideas and discussion to enrich the clinical expertise and cultural competence of the PA students and aid them in their understanding of patient perspective. The goals of the Community Plunge were:

Standardized Patient Instructors' and Physician Assistant Students' Evaluation of Diabetes Counseling Skills

Purpose: Standardized patient instructors (SPIs) have been used in medical and physician assistant (PA) teaching and have been shown to be a valuable resource for assessing interviewing and clinical skills. This study evaluated the agreement between SPI ratings and student self‐ratings in the assessment of counseling skills. Methods: PA students in three graduating classes (2009‐2011) participated in this study. SPIs received specialized training to simulate a patient with diabetes. SPIs provided feedback during simulated encounters using the Diabetes Risk Factor Interview Scale (DRFIS). The DRFIS provides a criteria‐based scale for student assessment. Students completed the DRFIS as a self‐assessment prior to receiving SPI feedback. Agreement between SPI evaluation and student self‐evaluation using the DRFIS were evaluated. Results: The total DRFIS score was generally comparable between all three graduation classes. SPI ratings of students by individual DRFIS items for all three classes indicate the highest scores occurred for Rapport and Empathy items while the lowest scores were evident for items including Reinforce Effort and Reframing Failure. The percent agreement between SPI and student self‐rating was within one point for greater than 70% for all 12 DRFIS items for the cohort of three graduation classes. Conclusion: PA students rated themselves on average lower on the DRFIS than SPIs but within an acceptable overall percentage range. Using an evaluation scale that is focused around patient counseling skills is a viable teaching tool for students and SPIs. Acceptable agreement between students and SPI was found. The DRFIS provides an effective criteria‐based scale for student assessment. J Physician Assist Educ 2013;24(4):9‐14

Medical Student Health Literacy Perspectives and Experiences

Objectives: To evaluate medical student perceptions of patient health literacy and provider abilities to assess patients’ health literacy and understand themes of student reports. Methods: Data was collected through a random selection process from 324 third year medical student descriptions of health provider interactions with patients. Students completed a one month required family medicine clerkship. A total of 130 (65 students) narratives were selected from 648 stories (approximately 20%) on student perspectives of effective and ineffective encounters experienced in their training. The Common Ground core communication components (information management, active listening, addressing feelings, and reaching common ground) were used to categorize major themes. Recurrent themes described frequently in narratives were also collected. Results: Medical students described a variety of scenarios they experienced in their first two or three years of medical school and 17 quotes from the narratives were selected from 130 stories. There were four dominant themes identified from student narratives that were related to communication. These categories included information management, active listening, addressing feelings and reaching common ground. Results suggest that medical students can identify effective and ineffective communication and health literacy skills and can describe how these experiences influence health care outcomes. Patient-perceived barriers, medications and diabetes were mentioned in about half of the narratives. Conclusions: Patients’ ability to read, comprehend and act on health information from providers is an essential part of health care delivery. Understanding the perspectives of medical students can reveal areas of communication related to health literacy that impact quality of care and outcomes.

Applied Relaxation & Applied Mindfulness (ARAM): A Practical and Engaging Approach for Mind-Body Regulation Training in Medical Education

Mind-body self-regulation techniques, including progressive muscle relaxation, biofeedback, the Relaxation Response, applied relaxation, and meditation, have been employed for the treatment of stress and mental health disorders and for moderating the causes and complications of acute and chronic medical illnesses for many years. More recently, interest has grown in the usefulness of forms of self-regulation training for mitigating the stresses of medical practice along with enhancement of professional performance. Medical schools have begun to include mindfulness training in their required curricula and many make the training available through electives or student health services. In this article, we describe a practical approach to self-regulation training that is a combination of applied relaxation and applied mindfulness (ARAM) designed to be cogent to third-year medical students. Approximately 150 students have practiced this approach and overall feedback has been positive.