James L. Sebastian

Learning/feedback activities and high-quality teaching: perceptions of third-year medical students during an inpatient rotation.

Purpose To identify specific learning activities (and teaching methods) that students associate with high-quality teaching in the inpatient setting. Method For ten months in 2003–04, 170 third-year medical students recorded data on learning/feedback activities and teaching quality via personal digital assistants during the inpatient portion of a required two-month medicine clerkship at four sites affiliated with the Medical College of Wisconsin. Univariate and multivariate analyses were performed to assess the association between learning/feedback activities and students’ perceptions of high-quality teaching. Results A total of 2,671 teaching encounters were rated by 170 students during their required inpatient medicine rotations. Bedside teaching was reported in almost two-thirds of teaching/learning encounters. Feedback on case presentation and differential diagnosis were the inpatient feedback activities most often provided by faculty. The univariate analysis revealed that students’ perceptions of high-quality teaching was associated with receiving mini-lectures, developing short presentations on relevant inpatient topics, bedside teaching, case-based conferences, learning electrocardiogram and chest X-ray interpretation, teaching with other team members present (p <. 001), and receiving feedback on history and physical examination, on case presentation, at the bedside, on differential diagnosis, and on daily progress notes. Results from the regression analysis revealed that giving mini-lectures on inpatient topics, teaching electrocardiogram and chest X-ray interpretation, providing feedback on case presentation, and at the bedside were predictors of overall high-quality teaching. Conclusions Aspects of feedback, giving mini-lectures, and learning test-interpretation skills were the learning and feedback activities associated with students’ perceptions of high-quality teaching. In an increasingly time-pressured inpatient environment, clinical educators should understand which activities students value.

Use of Oral Anticoagulants in Older Patients

Recently published American and British guidelines have comprehensively reviewed the indications for long term anticoagulation. The best evidence currently available supports the use of long term oral anticoagulants in patients with nonvalvular atrial fibrillation (NVAF), venous thromboembolic disease, ischaemic heart disease, mural thrombi, and mechanical heart valves. Selected patients with valvular heart disease, cerebral vascular disease, and peripheral arterial disease may also benefit from the use of these drugs.When no specific contraindications are present, elderly patients with either paroxysmal or persistent NVAF should be considered candidates for treatment with anticoagulants. Pooled analyses of the results from 9 randomised trials demonstrate that warfarin significantly reduces the risk of ischaemic stroke in patients with NVAF, particularly those in a ‘high risk’ category defined by the presence of additional clinical or echocardiographic risk factors. Long term anticoagulation does not appear to be justified in patients with NVAF considered to be at ‘low risk’ for stroke.Because the prevalence of NVAF and most other cardiovascular conditions increases with advancing age, many elderly patients will be candidates for thromboprophylaxis. The potential benefit of long term anticoagulation must be carefully weighed against the risk of serious haemorrhage in such patients. Bleeding complications with anticoagulant drugs appear to occur more frequently in older patients than in younger individuals. Advanced age (>75 years), intensity of anticoagulation [International Normalised Ratio (INR) >4.0], history of cerebral vascular disease (recent or remote), and concomitant use of drugs that interfere with haemostasis [aspirin (acetylsalicyclic acid) or nonsteroidal anti-inflammatory drugs] are among the most important variables in determining an individual’s risk for major bleeding with anticoagulants.Older patients often display increased sensitivity to the effects of warfarin, both in the early induction phase and during the long term maintenance phase of therapy. Conditions such as congestive heart failure, malignancy, malnutrition, diarrhoea and unsuspected vitamin K deficiency, enhance the prothrombin time response.The decision to interrupt anticoagulant therapy before elective surgery in elderly patients should evaluate the thrombotic risk of such a manoeuvre versus the risk of bleeding if anticoagulants are continued. In non-surgical patients, excessively elevated INRs without associated haemorrhage can usually be managed by simply witholding one or several doses of warfarin. If more rapid reversal is needed, small doses of phytomenadione (vitamin K1) can be administered safely without overcorrection or the development of vitamin K-induced warfarin resistance.

An Assessment of the Impact of Multimedia, Technology-Based Learning Tools on the Cardiac Auscultation Skills of Third-Year Medical Students

Abstract: Background: Previous studies have shown that medical students and post-graduate trainees need to improve their proficiency in cardiac auscultation. Technologic advances have created new learner-centered opportunities to enhance proficiency in this important physical examination skill. Objectives: We sought to determine if technology-based, self-directed learning tools improved the cardiac auscultation skills of third-year medical students. Methods: Sixteen (16) third-year medical (M3) students were exposed to three educational inter-ventions: a one-hour cardiac auscultation lecture that featured computer-generated heart sounds, a PDA-based heart sounds/murmur form and a web-based cardiac auscultation program. Thirteen (13) internal medicine (IM) residents who served as a comparison group attended a cardiac auscultation lecture identical in content and format to the student lecture. At the end of the study period, we evaluated the ability of both groups to accurately identify heart sounds and cardiac murmurs via a twelve-item performance-based examination utilizing computer-generated heart sounds. Results: Following our teaching interventions, findingsM3 students correctly identified 80% of the computer-simulated heart sounds/murmurs while the comparison group of IM residents accurately detected 60% of the same cardiac findings (p<. 005). Conclusions: The combination of traditional lecture and multi-media, technology-based, self-directed learning tools appears to be an effective and efficient strategy for teaching and reinforcing cardiac auscultation skills to third year medical students.

Learning Activities and Third-Year Medical Student Ratings of High Quality Teaching Across Different Clerkships

Objective: To identify and compare learning activities that students associate with high quality teaching across clerkships. Methods: For six months, 110 third year medical students recorded data on learning activities and teaching quality using personal digital assistants (PDAs) during five different required clinical clerkships. Univariate and multivariate analyses were performed to assess the association between learning activities and student ratings of high teaching quality. Results: 11,450 teaching interactions were recorded. Univariate analysis revealed that feedback was associated with perceptions of high quality teaching in all clerkships. Proposing a plan, formulating an assessment and giving an oral case presentation were associated with high quality teaching in 80% of the clerkships (p < 0.01). Multivariate analysis demonstrated that receiving high quality feedback was an independent predictor of student ratings of high quality teaching for all clerkships. Conclusion: Receiving high quality feedback is the learning activity most strongly associated with students’ ratings of high quality teaching across four different clerkships