Gary S. Ferenchick

Strategies for efficient and effective teaching in the ambulatory care setting

Medical education in the ambulatory care setting is characterized in part by the question of how to ensure educational effectiveness while simultaneously providing high-quality, cost-effective patient care. The constraints associated with managed care have only served to escalate the intensity of this dilemma. However, in spite of the difficulties faced by ambulatory care preceptors, there are educationally sound and time-efficient strategies clinical teachers may employ to improve ambulatory care education. Emphasizing the basic three-step process of planning, teaching, and reflection, the authors describe five such strategies: “wave” scheduling, orienting learners to patients, having learners do their case presentations in the examination room, employing the microskills of the “one-minute preceptor,” and effectively reflecting on ones teaching in order to develop effective teaching scripts. Research in ambulatory care learning has indicated that learners must be given significant roles in patient care and that preceptors must observe trainees as they care for patients so that they can provide trainees with helpful feedback. Employing these strategies in the ambulatory care setting will help educators to accomplish these two objectives while minimizing disruption to cost-effective, high-quality clinical practice.

Androgenic-Anabolic Steroid Abuse and Platelet Aggregation: A Pilot Study in Weight Lifters

The abuse of anabolic-androgenic steroids by athletes has recently been associated with the development of myocardial infarction and stroke. Because platelets play a pathogenic role in these disorders, the authors hypothesized that androgenic steroid abuse among weight lifters was associated with increased platelet aggregation as measured in vitro. Twenty-eight study participants were recruited. Twelve denied current androgen use. However, 8 of these 12 tested positive for urinary androgens. Nonsignificant trends toward increased platelet counts and increased platelet aggregation to adenosine diphosphate were noted when androgen users were compared to nonusers. However, when stratified by age, older (greater than 22 years) androgen users required lower concentrations of collagen to produce 50% aggregation of test platelets than did younger (less than or equal to 22 years) androgen users (1.47 versus 3.35 micrograms/ml; p = .01). Further subgroup analysis revealed nonsignificant trends toward increased adenosine diphosphate-induced aggregability and nonsignificant trends in the platelet count in older weight lifters. Subsequent studies using collagen threshold aggregometry revealed no age-dependent effect in 17 other men (aged 18 to 46 years) not specifically selected for activity (r = .17). This study suggests an association between androgen use, age, and increased platelet sensitivity to collagen in weight lifters and may be helpful in explaining recent thrombotic disease in androgen users. It additionally calls into question the validity of subjective reporting when assessing androgen use among weight lifters.

The medical problems of homeless clinic patients: a comparative study.

Objective:To compare the prevalences of major medical problems in homeless and nonhomeless patients.Patients:All 475 persons seeking care at an ambulatory clinic serving the medically indigent for one calendar year.Intervention:None.Measurements and main results:Demographic and clinical data were collected by structured interviews and medical record reviews for all patients seeking care at the clinic between March 1989 and April 1990. Comparisons were made between homeless patients, those patients with unstable housing, and those with stable housing. There was no significant between-group difference in age, gender, ethnicity, and health insurance coverage. Homeless patients were more likely to be unemployed (p<0.001) and were found to have higher prevalences of alcohol abuse, injuries/fractures, and dental and gynecologic problems (p<0.05).Conclusions:There were more similarities than differences in the prevalences of major medical problems in homeless vs. nonhomeless community clinic patients. Where differences did exist, homeless persons consistently had a higher prevalence of illness than did the non-homeless.

Identifying and overcoming the barriers to bedside rounds: a multicenter qualitative study.

Purpose The use of bedside rounds in teaching hospitals has declined, despite recommendations from educational leaders to promote this effective teaching strategy. The authors sought to identify reasons for the decrease in bedside rounds, actual barriers to bedside rounds, methods to overcome trainee apprehensions, and proposed strategies to educate faculty. Method A qualitative inductive thematic analysis using transcripts from audio-recorded, semistructured telephone interviews with a purposive sampling of 34 inpatient attending physicians from 10 academic U.S. institutions who met specific inclusion criteria for “bedside rounds” was performed in 2010. Main outcomes were themes pertaining to barriers, methods to overcome trainee apprehensions, and strategies to educate faculty. Quotations highlighting themes are reported. Results Half of respondents (50%) were associate or full professors, averaging 14 years in academic medicine. Primary reasons for the perceived decline in bedside rounds were physician- and systems related, although actual barriers encountered related to systems, time, and physician-specific issues. To address resident apprehensions, six themes were identified: build partnerships, create safe learning environments, overcome with experience, make bedside rounds educationally worthwhile, respect trainee time, and highlight positive impact on patient care. Potential strategies for educating faculty were identified, most commonly faculty development initiatives, divisional/departmental culture change, and one-on-one shadowing opportunities. Conclusions Bedside teachers encountered primarily systems- and time-related barriers and overcame resident apprehensions by creating a learner-oriented environment. Strategies used by experienced bedside teachers can be used for faculty development aimed at promoting bedside rounds.

Validity of self-report in identifying anabolic steroid use among weightlifters

To determine the validity of self-report in the detection of anabolic steroid use among weightlifters, self-report was compared with assay results of simultaneous urine samples from 48 male weightlifters. The sensitivity of self-report in the detection of urinary anabolic steroids was 74%, and specificity was 82%. In addition, 22 of 23 participants who declared current use had at least one undeclared anabolic steroid identified in their urine. However, 15 participants reported at least one drug that was not detected in the urine. Furthermore, 3 of 17 declared nonusers had objective evidence of steroids in their urine. The validity of self-report may be inadequate to differentiate reliably between users and nonusers.To determine the validity of self-report in the detection of anabolic steroid use among weightlifters, self-report was compared with assay results of simultaneous urine samples from 48 male weightlifters. The sensitivity of self-report in the detection of urinary anabolic steroids was 74%, and specificity was 82%. In addition, 22 of 23 participants who declared current use had at least one undeclared anabolic steroid identified in their urine. However, 15 participants reported at least one drug that was not detected in the urine. Furthermore, 3 of 17 declared nonusers had objective evidence of steroids in their urine. The validity of self-report may be inadequate to differentiate reliably between users and nonusers.

Medical Problems of Homeless and Nonhomeless Persons Attending an Inner-City Clinic: A Comparative Study

The identification of homelessness as a national problem has focused attention on defining the needs of this sizable population. Existing studies on the medical problems of the homeless are largely descriptive and are limited by lack of comparison to nonhomeless persons. To help fill this gap in knowledge, we conducted a retrospective study of the medical problems of homeless and nonhomeless persons cared for in an outpatient clinic serving the medically indigent. Homeless persons (n = 150) were more likely to be identified as alcoholic and to be seen for cuts and gynecologic problems than nonhomeless persons (n = 154) (p less than .01). There were no significant differences in the occurrence of other illnesses considered to be prevalent in the homeless. This study is among the first that validates descriptive data on the health problems of homeless persons by using concurrent nonhomeless controls. It may help in designing programs to meet the medical needs of the homeless.

Addressing mental health issues in primary care: an initial curriculum for medical residents.

OBJECTIVE Many express concern that modern medicine fails to provide adequate psychosocial and mental health care. Our educational system has not trained the primary care providers who care for most of these patients. Our objective here is to propose a quantum change: prepare residents and students during all years of training so that they are as effective in treating psychosocial and mental health issues as they are medical problems. METHOD We operationalize this objective, following Kern, by developing an intensive 3-year curriculum in psychosocial and mental health care for medical residents based on models with a strong evidence-base. RESULTS We report an intensive curriculum that can guide others with similar training interests and also initiate the conversation about how best to prepare residency graduates to provide effective mental health and psychosocial care. CONCLUSION Identifying specific curricula informs education policy-makers of the specific requirements they will need to meet if psychosocial and mental health training are to improve. PRACTICE IMPLICATIONS Training residents in mental health will lead to improved care for this very prevalent primary care population.

Outcomes of a National Faculty Development Program in Teaching Skills: Prospective Follow-up of 110 Internal Medicine Faculty Development Teams

BACKGROUND: Awareness of the need for ambulatory care teaching skills training for clinician-educators is increasing. A recent Health Resources and Services Administration (HRSA)-funded national initiative trained 110 teams from U.S. teaching hospitals to implement local faculty development (FD) in teaching skills.OBJECTIVE: To assess the rate of successful implementation of local FD initiatives by these teams.METHODS: A prospective observational study followed the 110 teams for up to 24 months. Self-reported implementation, our outcome, was defined as the time from the training conference until the team reported that implementation of their FD project was completely accomplished. Factors associated with success were assessed using Kaplan-Meier analysis.RESULTS: The median follow-up was 18 months. Fifty-nine of the teams (54%) implemented their local FD project and subsequently trained over 1,400 faculty, of whom over 500 were community based. Teams that implemented their FD projects were more likely than those that did not to have the following attributes: met more frequently (P=.001), had less turnover (P=.01), had protected time (P=.01), rated their likelihood of success high (P=.03), had some project or institutional funding for FD (P=.03), and came from institutions with more than 75 department of medicine faculty (P=.03). The cost to the HRSA. wwas

The Value of Bedside Rounds: A Multicenter Qualitative Study

22,033 per successful team and

Faculty Development Needs: Comparing Community-based and Hospital-based Internal Medicine Teachers

533 per faculty member trained.CONCLUSIONS: This national initiative was able to disseminate teaching skills training to large numbers of faculty at modest cost. Smaller teaching hospitals may have limited success without additional support or targeted funding.