Jeffrey G. Wong

Developing teaching skills for medical educators in Russia: a cross-cultural faculty development project

Context  Faculty development programmes have proved successful for improving teaching skills. We investigated whether or not a successful US‐based faculty development programme for improving the teaching skills of medical faculty could be transported to Russia.

Lifestyle factors and primary care specialty selection: comparing 2012-2013 graduating and matriculating medical students' thoughts on specialty lifestyle.

Purpose To compare how first-year (MS1) and fourth-year students (MS4) ascribe importance to lifestyle domains and specialty characteristics in specialty selection, and compare students’ ratings with their primary care (PC) interest. Method In March 2013, MS4s from 11 U.S. MD-granting medical schools were surveyed. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 lifestyle domains and 21 specialty selection characteristics. One-way analysis of variance was used to assess differences by PC interest among MS4s. Using logistic regression, ratings from MS4s were compared with prior analyses of ratings by MS1s who matriculated to the same 11 schools in 2012. Results The response rate was 57% (965/1,701). MS4s, as compared with MS1s, rated as more important to good lifestyle: time off (4.3 versus 4.0), schedule control (4.2 versus 3.9), and financial compensation (3.4 versus 3.2). More MS4s than MS1s selected “time-off” (262/906 [30%] versus 136/969 [14%]) and “control of work schedule” (169/906 [19%] versus 146/969 [15%]) as the most important lifestyle domains. In both classes, PC interest was associated with higher ratings of working with the underserved and lower ratings of prestige and salary. Conclusions In the 2012–2013 academic year, matriculating students and graduating students had similar perceptions of lifestyle and specialty characteristics associated with PC interest. Graduating students placed more importance on schedule control and time off than matriculating students. Specialties should consider addressing a perceived lack of schedule control or inadequate time off to attract students.

Primary Care, the ROAD Less Traveled: What First-Year Medical Students Want in a Specialty

Purpose Medical students are increasingly choosing non-primary-care specialties. Students consider lifestyle in selecting their specialty, but how entering medical students perceive lifestyle is unknown. This study investigates how first-year students value or rate lifestyle domains and specialty-selection characteristics and whether their ratings vary by interest in primary care (PC). Method During the 2012–2013 academic year, the authors conducted a cross-sectional survey of first-year medical students from 11 MD-granting medical schools. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 domains of good lifestyle and 21 characteristics related to specialty selection. The authors classified students into five groups by PC interest and assessed differences by PC interest using one-way analysis of variance. Results Of 1,704 participants, 1,020 responded (60%). The option “type of work I am doing” was the highest-rated lifestyle domain (mean 4.8, standard deviation [SD] 0.6). “Being satisfied with the job” was the highest-rated specialty-selection characteristic (mean 4.7, SD 0.5). “Availability of practice locations in rural areas” was rated lowest (mean 2.0, SD 1.1). As PC interest decreased, the importance of “opportunities to work with underserved populations” also decreased, but importance of “average salary earned” increased (effect sizes of 0.98 and 0.94, respectively). Conclusions First-year students valued enjoying work. The importance of financial compensation was inversely associated with interest in PC. Examining the determinants of enjoyable work may inform interventions to help students attain professional fulfillment in PC.

Bullous dermatosis associated with vancomycin extravasation.

Abstract:Cutaneous side effects related to vancomycin therapy have been reported including histamine-related reactions, linear IgA bullous dermatosis, Stevens-Johnson syndrome, maculopapular rash and drug rash with eosinophilia and systemic symptoms. In all instances, these reports were due to the systemic administration of vancomycin and subsequent immunological reactions to the medication. Drug extravasation into soft tissues can result in a variety of clinical outcomes usually related to physiochemical properties of the drug extravasated and its diluents or pharmacologic effects on the vasculature and tissue. The authors report a patient who experienced vancomycin extravasation that resulted in a localized bullous eruption resembling linear IgA bullous dermatosis, a phenomenon not previously described in the literature.

The role of USMLE scores in selecting residents.

To the Editor: McGaghie et al1 offer a summary of recent thinking about test validity, primarily citing the work of Kane. Kane suggests a strategy for validation research that focuses on the chain of inferences that supports the interpretation of examination results. However, McGaghie and colleagues’ discussion of the use of scores from the United States Medical Licensing Examination (USMLE) seems unnecessarily restrictive, in part because the authors limit both the aspects of Kane’s work and also the spectrum of relevant research considered.

Training using simulation in internal medicine residencies: an educational perspective.

Background:The American Board of Internal Medicine has defined through the min-CEX (Clinical Examination booklet) that a resident would need to perform anywhere from 3 to 5 procedures to be competent in a given procedure. Many faculty and residents believe that this number is too low to achieve competency. Methods:Although simulation has been required as part of medical training, we have reviewed a number of articles addressing competence and potentially fewer complications with improved patient safety. Results:The Accreditation Council for Graduate Medical Education has simply stated that simulation should be part of residency training. However, this has resulted in a disorganized approach among the nearly 385 internal medicine programs in the United States. Conclusions:This article suggests a model of simulation that addresses procedures, medical codes and major medical problems that each resident achieve competence in before graduating residency. This would require minimally a doubling of the number of procedures to define competency and will do so in a far more scientific method.

R-E-S-P-E-C-T—Implications for Physicians and Physicians-To-Be

To the Editor:—The study by Quigley and colleagues1 as well as the thoughtful commentary by Drs. Frosch and Tai-Seale2 shine the spotlight on a basic tenet of patient care—the need for the physician to demonstrate respect to her/his patients. While the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAPHS) survey collects data on five discrete aspects of physician behavior, whether or not a patient perceives that a physician is conducting his/her interactions in a respectful manner is certainly more difficult to extrapolate. When welcoming college graduates into medical school, we try to impress upon them this notion of respect, of medical professionalism, and the need for humanistic concern for the patients in their care. This is a daunting task for learners to achieve, and an even more difficult challenge for teachers to verbally express. However, the word “RESPECT” might be used as a mnemonic device to help learners remember, and to remind us all of those professional ideals to which all physicians should aspire.3 R is for demonstrating Respect—I would posit that this respect is not only for patients, but also for colleagues, other health professionals, for the profession of medicine as a whole, and importantly, for oneself. E is for Equanimity—this term was referred to by Sir William Osler in his Valedictory Address titled “Aequaminitas” and delivered at the University of Pennsylvania in 1889,4 where he exhorts physicians to cultivate “Imperturbability…coolness and presence of mind under all circumstances, calmness amid storm, [and] clearness of judgment in moments of grave peril.” Physicians are expected to be leaders, and equanimity is crucial for success. S is for Sincerity. Clear, honest and transparent communications between physician and patient is one of the expressed items in the CG-CAPHS survey, and sincerity, or perceived lack thereof, certainly impacts score in this fashion. P is for Perseverance. Physicians must continue to try and work harder for their patients, especially when the going gets tough. Not giving up when work becomes challenging, not just settling for a diagnosis when some of the history just doesn’t fit, not acquiescing to, but instead working to improve a system of care that fails to meet your patient’s needs—those are some of the persevering traits that define professionalism. E is for Excellence. Patients, for obvious reasons, want the best care possible. No one wants a mediocre doctor. And while sometimes it is human nature to “coast,” the better path is to continually strive for improvement. C is for Compassion. This compassion is demonstrated through empathetic communication and through one’s humanistic and altruistic actions—acting for the good of patients and placing this good of patients over one’s own self-interest. Francis Peabody’s oft-quoted line applies here, “…For the secret of the care of the patient is in caring for the patient.”5 Osler, in the aforementioned address Aequanimitas, urges physicians to, “Cultivate, then, such a judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening the human heart by which we live.”3 And T is for Trust. The professional physician cultivates trust from patients and family. It is not always easy to do, and can be lost very easily, but it is critical for good patient outcomes. The act of taking medications and undergoing invasive procedures is done at enormous personal risk to the patient; no wonder that physicians who effectively and respectfully communicate have gained the patient’s trust and satisfaction. My belief is that it really boils down to a trust issue, if the patient trusts what the doctor says, everything works better. All you really need to know about being a physician can be learned from Aretha Franklin!

When parallel worlds converge.

Earlier that year in the spring, I began having some pain in my mid-abdomen, possibly related to stress during my preparation for Step 1 of the National Board examination. The pain ultimately passed one day in late June after the examination was over. He was sent to the surgical ward at the University Hospital where a colonoscopy revealed a 12-cm fungating mass located near the splenic flexure of his transverse colon. The biopsy revealed mucinocystic adenocarcinoma and the abdominal CT scan demonstrated extensive metastatic spread. He was admitted to the surgical service where he underwent subtotal colectomy to relieve his impending bowel obstruction.

Teaching without lectures in the first year of medical school.

the case. In week 1, the faculty member and students met to share an introduction to PTEBL and instructions on clinical thinking, information retrieval, presentation and writing skills. Histories of the case were presented by the faculty member. Four problems were then extracted based on the histories: (i) differential diagnosis of osteoporosis; (ii) differential diagnosis of instability of gait; (iii) differential diagnosis of kidney damage, and (iv) the pharmacological mechanism of glucocorticoid and parathyroid hormone. After the session, the students searched for evidence and worked in teams to discuss and problem-solve the case presented. In week 4, a representative was chosen from each team to present the team’s answers to the four questions and a possible diagnosis of the case. Meanwhile, the faculty member showed the patient’s physical, laboratory and radiological examinations. The students found new problems based on the new information, discussed them in teams and achieved their own answers. In week 8, the four teams presented their final diagnoses and treatments for the patient. Finally, the faculty member revealed the diagnosis, explained how to differentiate it from other possible diseases and introduced the latest research on Wilson’s disease and osteoporosis. During the summer vacation, the students independently formed new teams to write academic papers. Finally, a questionnaire study was carried out among the students to assess the effect of PTEBL. What lessons were learned? The survey showed that most students demonstrated improvements in expressive skills (86%, 30 ⁄35), teamwork (97%, 34 ⁄35) and critical thinking (100%, 35 ⁄35), and that the greatest difficulties during PTEBL referred to weak literature retrieval capability (37%, 13 ⁄35) and the practical utility of materials (37%, 13 ⁄35). Three academic papers were submitted and one was published. It would appear from these results that PTEBL achieves an overall improvement in personal and group development, improves the ability of students to integrate skills, especially in terms of communication skills and critical thinking, and successfully prepares students for future clinical work. Despite some limitations, PTEBL is a creative attempt to develop a teaching strategy. Additional research is required to ascertain whether other benefits can be gained with the application of PTEBL, to develop an objective evaluation system and, finally, to widely implement PTEBL. Correspondence: Ruchun Dai, Institute of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China. Tel: 00 86 139 7488 4580; Fax: 00 86 731 8536 1472; E-mail: dairuchun@yahoo.com.cn

Access to Care: Too Much or Not Enough?

I thought that the first meeting would be the hardest but I was wrong; all of our meetings were difficult in their own way. My perspective was already clouded by the fact that he was referred to see me because Bill, a great doctor in his own right, wasn’t able to provided them what they needed: rather, what she needed—he was fine. In actuality, he was really, really sick—but not tragically so. At 85, he’d had a full life but over the past two to three years his body had begun to fail him. A more detailed history revealed that he’d had an MI almost 20 years ago, shortly thereafter developed atrial fibrillation and had a massive stroke several years after that—one that left him dysarthric and hemiparetic, though over time his deficits gradually and nearly completely resolved. In fact, these major past events had become relative afterthoughts, not unlike the hypertension and hyperlipidemia that caused them. He continued to be productive in his business and successful in his investments and when he partially retired and made our community one of his three United States residences, the people working in the development office certainly took notice. Thirty months ago, he noticed a sore on the back of his tongue. The ENT specialist also noticed lymphadenopathy on the contralateral side from the tongue lesion; a biopsy of the tongue revealed squamous cell carcinoma. A biopsy of the lymph node revealed non-Hodgkin’s lymphoma. So with two primary malignancies, three specialists (ENT, oncology and radiation oncology), and the might of the medical center behind him, he embarked on the double “full-court press”. No surgery was performed but radiation and chemotherapy “wrecked his body” as it simultaneously destroyed the dual tumors. In the throes of treatment, he was incredibly sick. A private duty nurses’ aide, one who had performed similar duties for wealthy, infirm patients in Manhattan and Long Island, was hired and summoned south to live with him and his devoted wife. This incredibly taxing 24-month vigil was deemed a success—both of the tumors were rendered undetectable by any radiographic means. He was cured! Except that the treatment had taken its toll. In the course of therapy, he had developed iatrogenic adrenal insufficiency from corticosteroids and autonomic dysfunction attributed to chemotherapy, requiring mineralocorticoids to support his blood pressure. With this turn of events, he acquired another specialist (an endocrinologist). In fact, what he lacked in blood pressure, he compensated for in specialists. His blood counts refused to return to normal (a hematologist). Atrial fibrillation and CHF impacted his condition (a cardiologist). He had “spells” during which he would blankly stare into space; on occasion his face would droop and his speech would become unintelligible. Whether these were TIAs or seizures was not determined but, as one might predict, he also gained a neurologist who treated him for both conditions. Not surprisingly, with his six specialists in tow, his care was fragmented, disjointed and disorganized. At one specialty visit, the physician would add medication; at another visit later in the week, a different specialist would discontinue it. More often then not, one manipulation made something else worse, so despite being cancer-free, he was frequently admitted to the hospital for short stays to sort things out. That’s when Bill got involved, the quintessential primary care general internist and geriatrician, perhaps the strongest advocate for the new health care plan and an expert on the patient-centered medical home. He saw them in his clinic and attempted to coordinate care, fielding phone calls and answering questions. He tried to ensure that all of the specialists were on, if not the same page, at least the same chapter in the story. And Bill did this all of this with his characteristic warmth, grace and good nature. But he hadn’t returned to his previous state of health, so she remained unhappy. The combination of his present ailments, his preexisting conditions, and his age rendered him frail, vulnerable, and ultimately dependent upon her care, and the care of his nurses’ aide. Despite everyone’s best efforts, despite requests for multiple blood tests and studies, he would still get very sick, very quickly and very unpredictably. So she removed him from Bill’s care and placed him in mine. I’d like to report that a fresh start with a new primary care physician made things better. In fact, he did show some improvement initially (perhaps a large amount of expectation bias and placebo effect) though I doubt it had anything directly to do with what I did or did not do. We had frequent visits— both in the clinic and in the hospital when he was admitted. During these hours spent together and without his wife present, he recognized the difficulty she had adapting to and accepting his present state of deteriorating health, seemingly understanding of the limits of medical science. All told, we were together for about four months—a period of time involving five office visits, three hospitalizations, and numerous phone calls (some to my personal cell phone). While it appeared that he wasn’t losing ground, he certainly wasn’t gaining. In most busy practices, and certainly in ours, not all phone messages are answered instantaneously, and while our office nurses and staff are some of the best around, she wasn’t happy with her access to our care. So they moved on again—to a local so-called “concierge” practice. I still see his name frequently on the hospital admissions roster and I wonder how he’s doing—how she’s doing—with the new arrrangement. I also wonder, if a “concierge” practice really is the answer, what that says about the essence of primary care. Primary care practices tread a fine line with wealthy “VIPs” and their families who are often accustomed to getting what they want whenever they want it; price is rarely an issue. And in academic medical centers, with budgets tightening and a growing emphasis on nuturing sources of philanthropy, there Published online September 28, 2011 JGIM