John R. Boker

Teaching empathy to first year medical students: evaluation of an elective literature and medicine course.

BACKGROUND Empathy is critical to the development of professionalism in medical students, and the humanities-particularly literature-have been touted as an effective tool for increasing student empathy. This quantitative/qualitative study was undertaken to assess whether reading and discussing poetry and prose related to patients and doctors could significantly increase medical student empathy and appreciation of the relevance of the humanities for their own professional development. METHOD In 2000-2001, first year students (n=22) volunteered for an eight-session literature and medicine elective and were randomly assigned to either immediate participation in the class or a wait-list group, who participated in the same class 6 months later. Complete pre- and post-intervention data for 16 students from both groups were obtained for two quantitative measures of empathy and an attitudes-toward-the-humanities scale. Students also participated in a qualitative group interview pre- and post-intervention. RESULTS Empathy and attitudes toward the humanities improved significantly (p<0.01) after participation in the class when both groups of students were combined. The scaled treatment effect size was in the moderate range (> or =0.60 standard deviation units) for both measures that had statistically significant pre-to-post changes. Furthermore, student understanding of the patients perspective became more detailed and complex after the intervention. Students were also more likely post-intervention to note ways reading literature could help them cope with training-related stress. CONCLUSION A brief literature-based course can contribute to greater student empathy and appreciation for the value of humanities in medical education.

Residents-as-teachers Training in U.s. Residency Programs and Offices of Graduate Medical Education

Resident physicians provide a substantial proportion of the teaching that medical students and junior residents receive, spending numerous hours every week teaching. As stated in the Graduate Medical Education Core Curriculum of the Association of American Medical Colleges (AAMC), residents’ teaching skills are vitally important, particularly for those residents who teach third-year medical students in the so-called ‘‘core clinical clerkships,’’ which traditionally include internal medicine, pediatrics, obstetrics–gynecology, surgery, psychiatry, and family medicine. Although the residency review committee of only one of these specialties (psychiatry) currently mandates residents’ training in teaching skills, the Liaison Committee on Medical Education (LCME) states that residents should ‘‘participate in teaching [clerkship] students’’ and ‘‘be prepared for their roles as teachers and evaluators.’’ Residency programs vary in their teaching-skills training for residents. Bing-You and Tooker found in a 1993 survey of internal medicine residencies that only 20% offered teaching-skills improvement programs for their residents. In most specialties, no published studies have ever documented how many such residents-as-teachers programs exist. To clarify the prevalence and characteristics of residents-as-teachers curricula in U.S. graduate medical education, a group of investigators collaborating with the AAMC’s Section for Graduate Medical Education surveyed directors of residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), as well as deans and directors of offices of graduate medical education (GME) at LCME-accredited medical schools.

Comparative survey of Complementary and Alternative Medicine (CAM) attitudes, use, and information-seeking behaviour among medical students, residents & faculty

BackgroundThere is significant and growing national interest for introducing Complementary and Alternative Medicine (CAM) instruction into allopathic medical education. We measured CAM attitudes, use, and information-seeking behaviors as a baseline to evaluate future planned CAM instruction.MethodsCross-sectional and longitudinal survey data on CAM attitudes, modality use, and common information resources was collected for (a) medical students (n = 355), (b) interns entering residencies in medical and surgical disciplines (n = 258), and (c) faculty from diverse health professions attending workshops on evidence-based CAM (n = 54). One student cohort was tracked longitudinally in their first, second and third years of training.ResultsCompared to medical students and interns, faculty who teach or intend to integrate CAM into their instruction had significantly (p < .0005) more positive attitudes and used CAM modalities significantly (p < .0005) more often. Medical students followed longitudinally showed no change in their already positive attitudes. The 3 survey groups did not differ on the total number of CAM information resources they used. Each group surveyed used about two out of the five common information sources listed, with the Internet and journals most frequently cited.ConclusionStudents, interns and a selected faculty group demonstrate positive attitudes toward CAM and frequently use various CAM modalities. CAM instruction should therefore be focused on acquiring knowledge of available CAM modalities and skills to appraise evidence to appropriately advise patients on best approaches to CAM use. Trainees may benefit from exposure to a wider array of CAM information resources.

Reliability and validity of an objective structured teaching examination for generalist resident teachers.

For more than a decade, medical educators have employed standardized students and objective structured teaching examinations (OSTEs) to evaluate the clinical teaching skills of medical faculty. Recent studies have set more rigorous standards of validity and reliability for these performance-based assessments. Some have begun using OSTEs for resident physicians, whom the Liaison Committee for Medical Education (LCME) and others increasingly recognize as critically important teachers for medical students and peers. OSTEs hold great promise for rapid and rigorous evaluation of clinical teaching skills and of new approaches to teacher training. For resident teachers and clinician–educators, it may require years to accumulate sufficient numbers of ‘‘real life’’ teaching evaluations for reliable teaching assessments. OSTEs can truncate this timeline to produce meaningful, prompt teaching assessments for important decisions such as resident evaluations or faculty promotions. OSTEs also facilitate outcomes-based educational research, as well as program evaluation of novel initiatives to improve teaching skills. A major challenge in OSTE practice lies in developing accurate rating scale or checklist instruments appropriate for carefully assessing teaching performance on OSTE stations. Although earlier research has delineated characteristics of exemplary clinical teachers, it remains a challenge to translate this body of knowledge into sensitive and specific assessment instruments. Educational researchers have developed and studied numerous instruments, some tailored to evaluating residents’ teaching skills. The SFDP-26, a 26-item rating scale based on the seven teaching constructs of the Stanford Faculty Development Program (SFDP), is one of the best-validated rating scales available to evaluate clinical teachers. The emerging OSTE literature has yet to address definitively the issue of selecting between dichotomously scored checklists and multi-point rating scales for best assessment of teaching performance. Research offers clearer support for using standardized students portrayed by senior medical students, who in non-OSTE studies have shown themselves to be capable evaluators of teaching. The related literature on objective structured clinical examinations (OSCEs) sheds light on some of these issues. Senior medical students who act as standardized patient examiners for learners may benefit by improving their own communication skills, suggesting that standardized students may improve their own teaching skills. The OSCE literature manifests more controversy over the choice between checklists and rating scales, with a minority of OSCEs featuring multi-point rating scales, although both formats can be used successfully. The purpose of our study was to develop and assess reliability and validity for an eight-station OSTE with case-specific, behaviorally-anchored rating scales, all developed specifically for resident teachers. This OSTE is the primary outcome measure for Bringing Education & Service Together (BEST), an ongoing randomized, controlled trial of a longitudinal residents-as-teachers curriculum at the University of California, Irvine (UCI). We hypothesized that our OSTE would demonstrate acceptable reliability and validity when used to evaluate generalist residents’ clinical teaching skills before and after a pilot administration of the BEST curriculum. Method

Using the tool for assessing cultural competence training (TACCT) to measure faculty and medical student perceptions of cultural competence instruction in the first three years of the curriculum.

Purpose To compare faculty and student perceptions of cultural competence instruction as measured by the AAMC’s Tool for Assessing Cultural Competence Training (TACCT) as part of a comprehensive curricular needs assessment. Method In 2005, 25 basic science and clinical course directors and 92 third-year medical students at the University of California, Irvine, School of Medicine were asked to indicate which of 67 separate items listed on the TACCT describing knowledge, skill, and attitude about cultural competence were covered during the first three years of the curriculum. The mean percentage of “yes” responses to each item was computed and compared for both faculty and students. Results Response rates were 100% (25/25) for course directors and 75% (69/92) for students. Students systematically perceived that cultural competence instruction occurred more often in the curriculum (range of 28% to 93% “yes” responses) compared to the faculty (range of 8% to 64%). However, faculty and students demonstrated a high level of concordance (intraclass correlation coefficient = 0.89 across all items) in their perceptions about instruction, as measured by their relative rank orderings of the 67 TACCT items. Students and faculty identified clusters of TACCT items pertaining to health disparities, community partnerships, and bias/stereotyping as least likely to be presented. Conclusions Faculty and third-year students at one medical school responded congruently about the relative degree to which cultural competence instruction occurred. The TACCT can be used to identify significant gaps in cultural competence training and inform curricular revision. Further studies involving other schools are warranted.

Using standardized patients to assess medical students' professionalism.

STANDARDIZED PATIENTS—WILL THE QUESTIONS NEVER END? Moderator: Craig Scott, PhD Using Standardized Patients to Assess Medical Students’ Professionalism ´ LIE, JOHANNA SHAPIRO, JOHN BOKER, and STEPHEN RADECKI MICHAEL D. PRISLIN, DESIREE The subject of professionalism is currently engendering great inter- est within the medical education community. Concern exists that conditions within the health care delivery environment threaten established standards of professional behavior, and, perhaps more insidiously, that the medical education experience itself may be negatively influencing the development of physicians’ profession- alism. 1–3 As a consequence, much energy has recently been directed toward defining competencies that reflect professionalism and in creating corresponding curricula that will foster learning in this domain. 4–6 However, having instruments that can accurately measure the attainment of professionalism remains an elusive goal. 7–9 This study examines the utility of standardized patient-based assessments of professional characteristics. Comparisons are made with other mea- sures of professionalism, such as faculty evaluation, performance on a written self-reflective exercise, and student-reported participation in community service activities. Method This study was conducted at the University of California, Irvine (UCI), College of Medicine. Participants were students completing the year two patient–doctor course during the 1999–00 academic year. This course represents the second segment of a vertically in- tegrated four-year course sequence in professional skill develop- ment. The year two segment focuses on patient–physician com- munications, physical diagnosis, and the development of basic clinical reasoning skills. Eight core clinical modules are linked to topics concurrently being taught in the year-two pathology, path- ophysiology, and pharmacology courses. Each module begins with a standardized patient interaction, followed by generation of learn- ing issues within small tutorial groups. Mid-module activities in- clude topical didactic presentations and physical diagnosis instruc- tion. Each module concludes with a wrap-up session in which the diverse learning activities are tied together through small-group dis- cussion of the original learning issues. These discussions typically feature a heavy emphasis on patient–physician communication and professional behavior. Assessments of students occurring during the course consist of a written final examination, structured written evaluations completed by the faculty group leaders, and an appraisal of clinical skills. The clinical skills appraisal for 1999–00 consisted of a three-station standardized-patient–based examination. The cases were a patient presenting with fatigue, a patient presenting with upper gastroin- testinal and chest discomfort, and a patient presenting with tran- sient neurologic deficits. The first two cases each entailed 25 minutes and the third case entailed 35 minutes of patient contact. Each station required students to perform a history and physical examination. In addition, students performed a rapid computer- based literature search following the initial encounter with the neu- rology case, written and oral clinical presentations following the fatigue case, and a written reflective essay, pertaining to students’ reactions to a poem describing a 39-year-old man experiencing an acute myocardial infarction and sudden death, following the upper gastrointestinal and chest pain case. Each standardized patient en- counter included assessments of history and physical exam perfor- mance based on a checklist and assessments of communication S90 skills and professionalism using a rating scale. The rating scale for communication skills used in this study was a modification of the Communications Skills Form developed at East Tennessee State University by Forrest Lang, MD, to assess patient-centered com- munications as evaluated by standardized patients. It is based upon an instrument developed by the American Board of Internal Med- icine to assess patients’ satisfaction. The rating scale includes six items relating to communication that are reported here as the cu- mulative communication score; a single item relating to overall professional competence; and a single item relating to overall stan- dardized patients’ satisfaction. The professionalism scale used for this study was constructed based upon the work of Arnold and colleagues, 9 and consisted of three items: one that allowed stan- dardized patients to rate students’ knowledge and competence, one that rated students’ integrity, and one that rated students’ altruism. Taken together, these three items are reported as the cumulative professionalism score. The specific rating scale items for commu- nication and professionalism are presented in List 1. Both the communication and the professionalism rating instru- ments used five-point Likert scales with the following specific an- chors: 5—outstanding; 4—very good; 3—good; 2—needs improve- ment; 1—marginal. Therefore, the maximum achievable scores were: cumulative communications—30 points, cumulative profes- sionalism—15 points, professional competence—5 points, and overall satisfaction—5 points. Standardized patients received de- tailed verbal and written instructions on how to complete the com- munication scale, including descriptive anchors for performance at varying levels of competence, and were observed rating perfor- mances using practice tapes before participating in the examina- tion. In terms of the specific professionalism items, the standardized patients were instructed to respond based upon their own personal perceptions of the students. Fourteen standardized patients were used during the course of the examination: seven for the fatigue case, three for the chest-discomfort case, and four for the neurology case. Faculty evaluations of students’ performances during the patient– doctor II course were based on an 11-item rating scale in which one item assessed whether the student ‘‘demonstrates professional behavior.’’ This evaluation also used a five-point Likert scale in which five represented outstanding, four represented above ex- pected, three represented at expected, two represented below ex- pected, and one represented problematic performance. Hence the maximum possible score for faculty professionalism ratings was five points. Evaluating faculty received verbal instructions regarding evaluating students’ performances during faculty development ses- sions. Evaluation of the professionalism item focused on students’ citizenship and academic honesty, team participation, and inter- actions with standardized patients during the interview sessions. The essay was scored by one of the study’s authors for emotional content and problem-solving capacity using a modification of a method described by Pennebaker and colleagues. 10 Subscale scores relating to empathy and positive coping attitudes were used as mea- sures reflecting students’ expressions of professional attributes. The scores students received represented a sum of these two subscales. Students’ descriptions of their participation in community ser- vice activities were elicited by means of a written survey distributed at the conclusion of the skills-appraisal exercise. Participation was scored as ‘‘did’’ or ‘‘did not’’ participate. A CADEMIC M EDICINE , V OL . 76, N O . 10 / O CTOBER S UPPLEMENT 2001

Interpreting Values Conflicts Experienced by Obstetrics-Gynecology Clerkship Students Using Reflective Writing

Purpose To examine students’ responses to reflective practice assignments used in medical ethics and professionalism education. The study goals include an examination of what reflective writing reveals about students’ personal and professional values, identification of the narrative typologies students use to tell stories of ethical dilemmas, and a determination of the usefulness of reflective writing in informing ethics/professionalism curricula assessment and development. Method This study employed a mixed-methods design generating both descriptive data and interpretive analysis. Students’ reflective writing assignments, guided by a series of six questions designed to elicit students’ perceptions of moral conflicts they have encountered and their personal and professional ethical values, were collected from three successive cohorts of third-year medical students (n = 299) from July 2002 to January 2006 during an obstetrics-gynecology clerkship at the University of California, Irvine, School of Medicine. Content, thematic, and global narrative analyses of students’ reflective writing were conducted, drawing on content analysis, grounded theory, and narrative methodologies. Results Values conflicts usually were patient centered (181; 60.5%) and student centered (172; 57.5%), without much regard for important contextual issues such as patients’ socioeconomic status, insurance coverage, or culture. Common personal values included religious beliefs (82; 27.4%), respect (72; 24.1%), and the Golden Rule (66; 22.1%); frequent professional values were respect (72; 25.1%), beneficence (71; 23.7%), nonmaleficence (69; 23.1%), and autonomy (65; 21.7%). Whereas 35.5% (106) claimed to have addressed conflicts, 23.4% (70) said they did nothing. Restitution narratives (113; 37.8%) dominated. Conclusions This analytic approach facilitated assessment of student values, conflict sources, and narrative types. Findings reveal aspects of the influence of the hidden curriculum and can inform strategies for effective implementation of bioethics/professionalism curricula.

Revising the Tool for Assessing Cultural Competence Training (TACCT) for curriculum evaluation: Findings derived from seven US schools and expert consensus

Abstract Background: The 67-item TACCT currently used for needs assessment has potential for evaluating evolving cultural competence (CC) curricula. Purpose: To validate a shortened, more practical TACCT measure. Methods: The 67-item TACCT was administered to students and course directors at US schools. Course directors and students reported which of 67 TACCT items were taught. Intraclass correlation coefficients (ICC) examined faculty-student agreement. Under-addressed content was identified. A new and shortened TACCT configuration was proposed and validated with expert educator input. Results: Across-school faculty and student response rates ranged from 75% to 100%. Aggregate ICC was 0.90 (95% CI: 0.84, 0.94) for the 67-item TACCT, demonstrating faculty-student agreement. Experts agreed on reduction from 67 to 42 items and domain revision from five to six domains to match under-addressed content. Item analysis showed high internal consistency for all 6 new domains and the total revised 42-item TACCT. Conclusions: A shorter, more practical TACCT measure is valid and reliable and focuses on under-addressed CC content. Use for curricular evaluation is suggested.

Reduced annexin II protein expression in high-grade prostatic intraepithelial neoplasia and prostate cancer.

CONTEXT Annexin II is a calcium-dependent phospholipid-binding protein that plays a role in many cellular functions, including apoptosis, signal transduction, and cellular motility. The protein is strongly expressed in normal prostatic epithelial glands, but its expression in benign prostatic lesions has not been reported. Although commonly underexpressed in prostate cancer, the association of reduced expression with pathologic grade and stage is unknown. OBJECTIVE To compare annexin II expression in benign prostatic lesions with expression in high-grade prostatic intraepithelial neoplasia and prostate cancer, as well as to correlate expression levels with pathologic grade and stage. DESIGN A semi-quantitative assessment of annexin II expression was performed in radical prostatectomy specimens from 74 patients and prostate needle core biopsy specimens from 13 patients. Foci with normal prostatic glands, atrophic glands, basal cell hyperplasia, high-grade prostatic intraepithelial neoplasia, and prostatic adenocarcinoma were evaluated. RESULTS Annexin II expression was present in more than 50% of glands in most (>85%) samples of benign prostatic epithelium, atrophic glands, and basal cell hyperplasia. In high-grade prostatic intraepithelial neoplasia, annexin II staining was markedly reduced in epithelial cells but not in basal cells. Annexin II was absent or focally present in moderately differentiated adenocarcinoma but was retained in poorly differentiated adenocarcinomas. CONCLUSIONS Reduced annexin II expression may be a useful diagnostic biomarker to help identify small foci of moderately differentiated adenocarcinoma on needle core biopsy specimens since it is consistently expressed in benign prostatic glands. Re-expression of annexin II in poorly differentiated adenocarcinoma may provide prognostic information.

Faculty training in evidence-based medicine: improving evidence acquisition and critical appraisal.

Introduction: Evidence‐based medicine (EBM) integrates published clinical evidence with patient values and clinical expertise, the output of which is informed medical decision making. Key skills for evidence‐based practice include acquisition and appraisal of clinical information. Faculty clinicians often lack expertise in these skills and are therefore unable to demonstrate this process for students and residents. Methods: We conducted a yearlong case‐based EBM workshop for 28 clinician educators, with precourse and postcourse evaluations of EBM resource use and literature appraisal skills. Results: Of the original 28 participants, 26 completed the course. Self‐assessed EBM resource use improved significantly. Self‐reported EBM knowledge correlated with measured skill (r = 0.45), and both improved with the intervention (both p < .001). Higher EBM skills scores correlated with time logged on the courses EBM Web sites (r = 0.56; p < .05), workshop attendance rates (r = 0.55; p = .003), and fewer years since medical school graduation (r = −0.56; p < .005). Discussion: An interactive, longitudinal, EBM course derived from a needs assessment can improve 2 skills important for evidence‐based practice: online literature retrieval and critical appraisal skills.