John C. Rogers

Medical student attitudes toward the doctor–patient relationship

Context  Medical educators have emphasized the importance of teaching patient‐centred care.

Medical students' attitudes toward patient-centered care and standardized patients' perceptions of humanism: a link between attitudes and outcomes.

The physician–patient relationship is central to the delivery of high-quality medical care and has been shown to affect patient satisfaction and a variety of other biological, psychological, and social outcomes. Patient-centered care is one aspect of the physician–patient relationship that takes into account patients’ preferences, concerns, and emotions and has been proposed as a mechanism through which favorable patient outcomes are achieved. In recent years, medical educators have recognized the importance of patient-centered care by instituting a variety of curricula to teach communication skills, professional values, and patient-centered behaviors to medical students. Despite the presence of such curricula, we recently demonstrated that medical students have less patientcentered attitudes in later years of medical school. Our quantitative results augment a large body of qualitative and ethnographic data that suggest that the culture of medical education emphasizes biomedical issues at the expense of patients’ preferences, concerns, and emotions. However, few data exist regarding the clinical significance of students’ patient-centered attitudes. Understanding the clinical significance of students’ attitudes is critical in the present context of ongoing debate about the relative merits of teaching attitudes versus skills in order to promote greater patient-centered care and improve patients’ outcomes. In this study, we explored associations between students’ attitudes toward patient-centered care and standardized patients’ perceptions of humanism, a construct commonly included in patient-satisfaction outcome measures.

The patient-centered medical home movement--promise and peril for family medicine.

“Strengthen the Core and Stimulate Progress: Assembling Patient-Centered Medical Homes” was the theme of my year as the Society of Teachers of Family Medicine President for 2007 to 2008. I advocated strongly for the patient-centered medical home (PCMH), especially its relevance to the

Laparoscopic adjustable gastric banding for the treatment of morbid obesity

BACKGROUND This prospective study evaluated the effectiveness and safety of laparoscopic adjustable gastric banding (LAGB) for morbid obesity. METHODS Ninety-five consecutive patients (89 female; median age 38 years, range 19 to 69) underwent LAGB for morbid obesity. Median weight and body mass index were 123.2 (88.9 to 228.6) kg and 45 (32.7-76.4) kg/m(2) respectively. Significant coexistent disease was present in 52 (55%) patients. RESULTS Median excess weight loss was 53% (range 96.9% to 12.1%) and 62% (range 107.5% to 32.3%) at 1 and 2 years respectively (P <0.001). Median operative time was 90 (range 35 to 285) minutes and inpatient stay 2 (range 1 to 10) days. Early complications were seen in 17 (18%) patients most commonly nausea/vomiting or dysphagia. Late complications were seen in 25 (26.3%) patients, most frequently vomiting or reflux due to band slippage or pouch dilatation. There was 1 (1%) operative death. CONCLUSIONS LAGB is an effective operation for morbid obesity that results in equivalent weight loss to open surgical procedures.

Do students' attitudes during preclinical years predict their humanism as clerkship students?

There is an increased awareness of the importance of humanism in the medical school curriculum. Most of the early work concerned teaching methods and measurement of humanism. Contemporary work reinforces the critical role of empathy in humanism but also broadens the concept to include other values, qualities, and behaviors: authenticity, compassion, fidelity, integrity, respect, spirituality, and virtue. To distinguish it from humanism, professionalism is characterized as accountability, altruism, commitment to excellence, duty and commitment to service, and honor and respect for others. The project we report here began over eight years ago, so compassion, empathy, respect, and considerate biopsychosocial interactions are the conceptual cornerstones of the operational definition we used in this work; we therefore defined the humanistic physician as one who

Aspiring to leadership—identifying teacher-leaders

Educational institutions need effective leaders at many levels. This paper explores the applicability of the Porter/Mazlow need-priority and Herzberg maintenance-motivation models to the challenge of identifying individuals who aspire to leadership. The review includes literature from teaching, engineering, medicine, astronomy, business, and the military. Autonomy need and achievement motivation consistently distinguished leaders from non-leaders in several studies. Affiliation and esteem needs also characterized leaders in two studies. These empirical data support the use of these theoretical models, which are intuitively appealing and have potential for practical applications. One such application could be the identification and recruitment of education “champions” who would be teacher-leaders at dispersed sites. Through self-reflection faculty members could become aware of their needs and motivations and may realize their leadership aspirations and accept the teacher-leader role. For an education “champions” program to be successful, the department leadership would need to attend to the organizational culture and provide release time for the teacher-leaders. A blueprint for the development of teacher-leaders is outlined.

Cross-Sectional Comparison of Electronic and Paper Medical Records on Medication Counseling in Primary Care Clinics: A Southern Primary-care Urban Research Network (SPUR-Net) Study

Introduction: This study compared the frequency of oral counseling and written information by primary care physicians at paper medical record (PMR) clinics and electronic medical record (EMR) clinics, and assessed relationships between medication counseling and medication outcomes (knowledge, questions, reported adherence and side effects, and medication fill). Methods: A cross-sectional study with two convenience samples of English-speaking adult patients receiving ≥1 prescription at the primary care index visit was conducted in two PMR clinics, with 184 (48% response) patients seen by one of 22 physicians, and in two EMR clinics, with 249 (37% response) patients seen by one of 25 physicians. Data were from medical record reviews of the index visit and 2-week post-visit telephone interviews. Results: Three mutually exclusive counseling categories were evaluated. Patients received 1,095 prescriptions, 61% with oral counseling for indications, 21% with oral counseling for indications and side effects, and 12% with written information plus oral (“multi-mode”) counseling. General linear mixed models found 1) less multi-mode counseling in PMR clinics (2%) than EMR clincs (20%); 2) PMR and EMR clinics were similar in oral counseling for indications and side effects; and 3) PMR clinics provided more oral counseling only for indications (69%) than EMR (53%) clinics. The impact of receiving oral or written counseling on patients’ reports of having questions about their medications was inconclusive. Not receiving oral counseling for indications was associated with more questions, but not receiving written information was associated with fewer questions. Filling a prescription was lower when no oral counseling for indications and side effects was reported, but the absence of written information was associated with more prescriptions fills. Conclusions: Physicians’ use of EMR to print medication information did not seem to compromise their oral counseling for medication indications and side effects. This feature of the EMR was underutilized by physicians; however, future studies addressing patient recall and evaluating the quality and content of medication counseling are needed.

The SAGE-PAGE Trial: Do Family Genograms Make A Difference?

Background: Despite enthusiastic promotion of family genograms, the impact of routine use of this tool on clinical practice has not been systematically examined. The present study investigated whether doing a genogram, or having one available, makes physicians more sensitive to psychosocial issues or in other ways affects the physician-patient relationship or the process of clinical care. Methods: In a randomized clinical trial, patients visiting 5 physicians at an academic family practice center (n = 189) received a physician-administered genogram (PAGE); a self-administered genogram (SAGE), which the patient completed before seeing the physician; or no genogram. A fourth (baseline) group was tested without genograms prior to the randomized trial. Results: Analyses of patients’ and physicians’ postencounter questionnaires showed no impact of genograms on how physicians think about and deal with clinical problems or how patients view the encounter with their physicians. Compared with control groups, neither patient- nor physician-administered genograms increased the physician’s (self-defined) understanding of the patient or the importance the physician attached to psychosocial issues in the case. A positive finding was that physicians considered genograms more relevant when they did them themselves. On the other hand, physician-administered genograms also increased the length of the encounter and were substantially less complete (conveying less information) than genograms completed by patients. Conclusions: The results leave open the possibility that genograms do make a difference when used routinely by residents or experts or in difficult cases when family assessment is indicated. While enthusiasm about genogram applications in family medicine is understandable, the clinical utility of this tool remains to be demonstrated scientifically.

Medical student exposure to components of the patient-centered medical home during required ambulatory clerkship rotations: implications for education.

Purpose To determine the extent to which third-year medical students are exposed to elements of the patient-centered medical home (PCMH) during required family medicine (FM) clerkships and how this exposure varies among a sample of medical schools. Method In 2008, the authors conducted a cross-sectional survey of 104 ambulatory teaching practices that host required third-year FM clerkship students from nine U.S. medical schools. Descriptive statistics characterized learning settings and the status of PCMH features, and generalized linear mixed models examined variation among medical schools (as the 104 clinics were nested within nine medical schools). Results Participating schools captured data on 104 eligible clerkship sites (44%). These practices were primarily community-based, single-specialty clinics (n = 48; 46%), and more than half (n = 55; 53%) were part of integrated health systems. Electronic health records (EHRs) were in place in 60 (58%), and no significant difference existed in EHR use according to medical school, despite up to a 10-fold variation from school to school in other PCMH features. Among sites with EHRs, 8 (14%) did not allow access to medical students. Preceptor attitudes about how practice transformation and new information technology are affecting the quality of medical education differ widely from site to site. Conclusions Primary care transformation toward the PCMH is already well under way in a national sample of FM teaching sites, and this transformation is having important effects on medical student education.

Exploring the learning curve in medical education: using self-assessment as a measure of learning.

Background Learning is a complex process that follows predictable patterns. The authors explored whether students’ self-assessment of competencies could be used as a measure of learning within medical school. Method Medical students (all grade levels) rated their achievement of competencies at the beginning and end of an academic year. Repeated-measures ANOVA and &eegr;2 were used to determine differences. Results Five hundred thirty-three students participated (response rate = 79.3%). Self-assessment ratings between four grade levels were significant (P < .001, &eegr;2 = 0.33), with the steepest difference between MS2 and MS3; professionalism ratings remained relatively stable. The largest percent increase within an academic year occurred between MS1 and MS2, with little increase within MS3 and MS4. Conclusions Medical students’ self-assessment ratings of competencies indicated differences between grade levels and during an academic year, following a sigmoidal curve. These results have implications for medical education and indicate the need to develop longitudinal measures to track changes in learning.