Jennifer Stojan

Teaching Patient- and Family-Centered Care: Integrating Shared Humanity into Medical Education Curricula

The University of Michigan Medical School (UMMS) implemented a major curriculum revision to incorporate patient- and family-centered care concepts.

Medical school handoff education improves postgraduate trainee performance and confidence

Abstract Objectives: Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training. Methods: About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p < 0.05. Results: About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p < 0.05); they were also more confident in their handoff abilities (p < 0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p < 0.05). Conclusions: This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.

The impact of informed self-assessment on the development of medical students’ learning goals

Abstract Purpose: This study investigates the contributions of self-assessment (SA) and external feedback on the development of learning goals (LG) and the influence on LG recall and implementation in medical students. Methods: Following a standardized patient (SP) assessment, 168 pre-clinical medical students completed a SA, received SP feedback and created a LG. LG were categorized by source. Two weeks later, students recalled LG and described implementation. Chi-squared analyses were used to test the associations. Results: SA influenced LG for 82.8% of students whereas SP feedback influenced LG for 45.9%. Students rarely generated LG based on SA when they received discordant feedback (5.4%), but sometimes incorporated feedback discordant from their SA into LG (14.9%). Students who created LG based on SP feedback were more likely to recall LG than those who created LG based on SA, 89.7 versus 67.6%, p < 0.05 and implement their LG, 72.4 versus 48.9%, χ2(1) = 5.3, p = 0.017. Students who reported receiving effective feedback were more likely to implement their LG than those reporting adequate feedback, 60.9 versus 37.9%, χ2(1) = 8.0, p = 0.01. Conclusions: SA is an essential part of goal setting and subsequent action. Perception of feedback plays a crucial role in LG implementation.

A Randomized Cohort Study of Diagnostic and Therapeutic Thresholds in Medical Student Clinical Reasoning

Purpose Learning to make decisions under uncertain conditions is a critical component of diagnostic and therapeutic reasoning. This study sought to determine treatment decisions medical students make when presented with different thresholds of diagnostic uncertainty and whether they appropriately adjust diagnostic probabilities with test information. Method Two classes (2015, 2016) of fourth-year students (N = 342) were presented a patient with viral pneumonia and given 10%, 20%, or 50% pretest probabilities of that patient having a superimposed bacterial infection. Students decided to not treat, order a diagnostic test to guide management, or treat without testing based on these probabilities. The 2015 class was provided a posttest probability of 10% or 50% and asked to adjust their initial treatment decision. Results When given a low (10%) pretest probability, students were less likely to decide to treat (6%) and more likely to decide not to treat (36%). The percentage of students deciding to treat increased as the pretest probability of a superimposed infection increased from 10% to 50%, while the percentage of students not wanting to treat decreased. Interestingly, at 10%, 20%, and 50% pretest probability levels, most students were unable to decide and chose to order another test (57%, 67%, and 64%, respectively). When provided low and high posttest probabilities, students appropriately adjusted their decision making, but 29% to 32% still wanted additional testing. Conclusions Students adjusted treatment decisions to reflect different levels of diagnostic uncertainty, but varied considerably in their individual thresholds to make decisions, possibly contributing to unnecessary testing.

Handover education improves skill and confidence

Despite the frequency of patient‐care handovers and vulnerability to errors, medical schools infrequently teach handover skills. Our study evaluated the impact of a medical school handover curriculum on students’ performance, as rated by faculty members, peers and self‐assessment.

Assessing patient-centred care through direct observation of clinical encounters

Patient-centred care, defined as respecting and responding to the needs and preferences of patients, empowering them to make decisions that best fit their individual needs, has been identified by the Institute of Medicine as an essential element of high-quality care.1 It can be thought of as respectfully involving the patient2 in a way that helps practitioners provide care that is concordant with their patients’ values, needs and preferences while better enabling patients to actively provide input and participate in their healthcare.3 Patients are more satisfied with their care when they feel that healthcare providers are understanding their needs, carefully listening and clearly providing information4; in addition, patient-centred care has been found to be associated with improved patient outcomes.5 In order to provide exemplary patient-centred care, one needs well developed communication skills, especially in the realm of active listening and responding to patient cues. The importance of physicians mastering the art of patient-centred communication skills can be seen as a theme in the educational objectives of medical school curricula as well as in the competencies of the Accreditation Council for Graduate Medical Education.2 Approaches to evaluating patient-centred communication skills include patient surveys that assess satisfaction with a healthcare provider6 and direct observation. Training programmes employ standardised patients to directly observe communication skills such as with Objective Structured Clinical Examinations.7 Direct observation can also occur in real time or through videotaped or audiotaped real patient encounters. When using audiotaped encounters, the ‘Content Coding for Contextualization of Care’ or 4C method can be used to evaluate clinical care performance.8 With this method, audio recordings of patient–provider encounters are used to assess whether care planning has taken …

Educational Interventions to Improve Handover in Health Care: An Updated Systematic Review

Purpose Effective handovers (handoffs) are vital to patient safety. Medical educators investigated educational interventions to improve handovers in a 2011 systematic review. The number of publications on handover education has increased since then, so authors undertook this updated review. Method The authors considered studies involving educational interventions to improve handover amongst undergraduate or postgraduate health professionals in acute care settings. In September 2016, two authors independently conducted a standardized search of online databases and completed a data extraction and quality assessment of the articles included. They conducted a content analysis of and extracted key themes from the interventions described. Results Eighteen reports met the inclusion criteria. All but two were based in the United States. Interventions most commonly involved single-patient exercises based on simulation and role-play. Many studies mentioned multiprofessional education or practice, but interventions occurred largely in single-professional contexts. Analysis of interventions revealed three major themes: facilitating information management, reducing the potential for errors, and improving confidence. The majority of studies assessed Kirkpatrick’s outcomes of satisfaction and knowledge/skill improvement (Levels 1 and 2). The strength of conclusions was generally weak. Conclusions Despite increased interest in and publications on handover, the quality of published research remains poor. Inadequate reporting of interventions, especially as they relate to educational theory, pedagogy, curricula, and resource requirements, continues to impede replication. Weaknesses in methodologies, length of follow-up, and scope of outcomes evaluation (Kirkpatrick levels) persist. Future work to address these issues, and to consider the role of multiprofessional and multiple-patient handovers, is vital.

Experiential learning about medication adherence

Why is there a need for change? The term noncompliance implies patients should simply follow their doctor ’ s orders, rather than actively engage as participants in their own health care. The term can be stigmatising, derogatory and negatively affect the relationships that patients have with their current and future health care providers. 2 Despite this, many practising doctors persist in using the term noncompliant, fail to inquire about barriers to adherence, believe it is the patient ’ s responsibility to follow their orders and become frustrated when patients are nonadherent. 3

Case 1: Intractable Rash in a 7-month-old Boy.

1. Priyanka Rao, MD* 2. Jennifer Stojan, MD* 1. *University of Michigan Mott Children’s Hospital, Ann Arbor, MI. A 7-month-old previously healthy boy presents with a diffuse rash. Three months ago he developed an erythematous perioral rash that spread to his trunk and extremities. The rash persisted despite treatment with numerous corticosteroid creams, antibiotic courses, and antifungal treatments. The rash is not pruritic or painful, and he has been afebrile. He has also had hair loss. The boy has no history of diarrhea, viral respiratory tract infections, acute otitis media, or other rashes. He is growing and developing appropriately and is up-to-date on his immunizations. He breastfeeds without difficulty and in the last month has begun to eat a small amount of soft, age-appropriate foods. His general skin care consists of three to four baths per week with lukewarm water. He is moisturized with petroleum immediately following his baths. His family has been trying tar shampoo and uses fragrance-free laundry detergent. On physical examination, his vital signs are all within age-appropriate ranges, and he appears well. His weight is 8.5 kg (31st percentile), length is 70 cm (41st percentile), …

Case 2: Respiratory distress and abdominal tenderness in 21-month-old girl.

1. Heather Lesage-Horton, MD* 2. Gina Ney, MD, PhD* 3. Jennifer Stojan, MD* 1. *Department of Pediatrics, University of Michigan, Ann Arbor, MI. A 21-month-old girl with asthma and eczema (treated by albuterol and topical hydrocortisone as needed) presents in January with 5 days of cough, rhinorrhea, and fever. One day before presentation, she developed emesis and diarrhea with a decrease in oral intake and urine output. On presentation, her temperature is 101.7oF (38.7oC), with a respiratory rate of 60 breaths per minute, a pulse of 160 beats per minute, blood pressure of 110/68 mm Hg, and an oxygen saturation of 91% on room air. Mucous membranes are dry, and capillary refill is delayed. She is responsive but in moderate respiratory distress with intercostal and subcostal retractions. Crackles and coarse breath sounds are auscultated bilaterally. She has abdominal distension with significant right upper quadrant tenderness and guarding. Laboratory results are remarkable for a blood glucose level of 40 mg/dL (2.2 mmol/L), venous pH 7.15, lactate level of 73.9 mg/dL (8.2 mmol/L), bicarbonate level of 16 mEq/L (16 mmol/L) with an anion gap of 17 mEq/L (17 mmol/L), aspartate aminotransaminase (AST) level of 789 IU/L, and alanine aminotransaminase (ALT) of 301 IU/L. Resuscitation with 25% dextrose achieved normal blood glucose levels, and further fluid resuscitation with 2 normal saline boluses followed by 5% dextrose and 0.45% normal saline was administered. Her total bilirubin level is 1.0 mg/dL (17.1 μmol/L) with an alkaline phosphatase level of 271 IU/L. Serum albumin, protein, …