Katherine A. Julian

A Literature Review of “Resident-as-Teacher” Curricula: Do Teaching Courses Make a Difference?

AbstractOBJECTIVES: To examine the evaluation methods of resident teaching courses and to estimate the effectiveness of these teaching courses. DESIGN: We searched the literature from 1975 to May 2003 using the PubMed MESH terms internship and residency and teaching; 1,436 articles were identified and 77 contained information regarding teaching courses. Fourteen articles contained information regarding outcomes of resident teaching courses and were selected for intensive review. MAIN RESULTS: Five uncontrolled pre-post studies used resident self-reported teaching skills/behaviors as outcome measures; all reported some improvement in self-reported skills. Three uncontrolled pre-post studies examined live or videotaped resident teaching encounters and all revealed improvement in some teaching skills. One uncontrolled trial and three nonrandomized controlled trials used learner evaluations of resident teaching behaviors as outcomes and all revealed an improvement in ratings of residents after course participation. Four randomized controlled trials of resident teaching curricula are included in this review. One study did not show any quantitative benefit of a resident teaching course on performance on an objective structured teaching evaluation. Two studies assessing resident teaching evaluations before and after course participation showed conflicting results. One study noted improvements in resident teaching skills assessed through videotape analysis. CONCLUSIONS: Resident teaching courses improve resident self-assessed teaching behaviors and teaching confidence. Teaching courses are linked to improved student evaluations. Further studies must be completed to elucidate the best format, length, timing, and content of resident teaching courses and to determine whether they have an effect on learner performance.

Perspective: Creating the next generation of general internists: a call for medical education reform.

The United States is faced with an increasing shortage of physicians in the primary care workforce. The number of medical school graduates selecting careers in primary care internal medicine has fallen dramatically since 1985. Although political, financial, and organizational reform of the medical system is necessary, these changes will address only part of the problem. Endeavors designed to ameliorate this current crisis in primary care practice must also address the education and training of future primary care internists. Learners require specialized training in primary care internal medicine to be able to provide high-quality, patient-centered, outcome-oriented care. This article examines the impact of educational interventions in undergraduate medical education (UME) and graduate medical education (GME) on primary care internal medicine career choice and makes suggestions for future educational changes. Suggested UME changes include providing early longitudinal clinical experiences and providing the option for an integrated ambulatory third year of training. Suggested GME changes include early, sustained exposure to general internal medicine and differentiated training tracks for residents interested in primary care. Key among these changes are that medical students and residents must have adequate mentorship from primary care internists and clinical experiences in highly functioning primary care settings established as patient-centered medical homes. Academic centers have a unique opportunity to contribute to these imperatives by reengineering the practice of primary care in a way that embodies the core values of effective, patient-centered care.

The Impact of an Objective Structured Teaching Evaluation on Faculty Teaching Skills

Background: Objective structured teaching evaluations (OSTEs) have been utilized to evaluate educational curricula and for resident and faculty development. Purpose: This study examines the impact of an OSTE on faculty teaching effectiveness and faculty satisfaction. Methods: From 2004 to 2007, 46 faculty members participated in the OSTE. Faculty assessed their teaching abilities with a retrospective pre-post-test analysis. Faculty teaching evaluations for the 6 months before and after the OSTE were compared. Faculty participants completed satisfaction questionnaires regarding their OSTE experience and made teaching plans for the future. Results: After the OSTE, faculty reported statistically significant improvements in all self-assessed teaching skills. There was, however, no improvement in their teaching evaluations. Faculty satisfaction with the OSTE experience was high. They indicated teaching plans incorporating lessons from the OSTE. Conclusions: Faculty felt the OSTE was a rewarding experience and reported improvement in their teaching abilities; however, faculty teaching evaluations did not improve.

Using Needs Assessment to Develop Curricula for Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Academic and Community Health Settings.

ABSTRACT This article describes the use of a brief needs assessment survey in the development of alcohol and drug screening, brief intervention, and referral to treatment (SBIRT) curricula in 2 health care settings in the San Francisco Bay Area. The samples included university medical center faculty (n = 27) and nonphysician community health and social service providers in a nearby suburban county (n = 21). Informed by curriculum development theory and motivational interviewing strategies, questions regarding clinical and educational priorities, perceived importance and confidence with screening and intervention techniques, and referral resource availability were included. Medical center faculty expressed greater concern about limited appointment time (P = .003), adequacy of training (P = .025), and provider confidence (P = .038) as implementation obstacles and had lower confidence in delivering SBIRT (P = .046) and providing treatment referrals (P = .054) than community providers. The authors describe their approach to integrating needs assessment results into subsequent curriculum development. Findings highlight potential differences between physician and nonphysician training needs.

Using an objective structured teaching evaluation for faculty development

Medical Practice) and ROL (Reflecting on Learning). Needs assessment is integral to the process as topics are derived from faculty concerns. ROMP is a hybrid of quality assurance and physician support group. Topics, suggested at each meeting, included issues of communication, ‘difficult patients’, professionalism, mistakes in care and identity of doctoring. ROL is a series on varied aspects of teaching in the outpatient and inpatient settings. It linked facultygenerated concerns and group discussion. It utilised several formats, appropriate to the topic:

Team-Based Learning Exercise Efficiently Teaches Brief Intervention Skills to Medicine Residents.

ABSTRACT Background: Evaluations of substance use screening and brief intervention (SBI) curricula typically focus on learner attitudes and knowledge, although effects on clinical skills are of greater interest and utility. Moreover, these curricula often require large amounts of training time and teaching resources. This study examined whether a 3-hour SBI curriculum for internal medicine residents utilizing a team-based learning (TBL) format is effective for SBI skills as measured by a standardized patient (SP) assessment. Methods: A waitlist-controlled design was employed. Results: Twenty-four postgraduate year 2 (PGY-2) and PGY-3 residents participated in a SP assessment prior to the TBL session (waitlist control group) and 32 participated in a SP assessment after the TBL session (intervention group). The intervention residents demonstrated better brief intervention skills than waitlist control residents, but there were no differences between the groups in screening and assessment skills. Residents receiving the TBL curriculum prior to the SP assessment reported increased confidence in all SBI skills. Conclusion: Findings indicate that a brief educational intervention can improve brief intervention skills. However, more intensive education may be needed to improve substance use screening and assessment.

Internal Medicine Residents’ Perceptions of Team-Based Care and its Educational Value in the Continuity Clinic: A Qualitative Study

ABSTRACTBACKGROUNDIn order to teach residents how to work in interprofessional teams, educators in graduate medical education are implementing team-based care models in resident continuity clinics. However, little is known about the impact of interprofessional teams on residents’ education in the ambulatory setting.OBJECTIVETo identify factors affecting residents’ experience of team-based care within continuity clinics and the impact of these teams on residents’ education.DESIGNThis was a qualitative study of focus groups with internal medicine residents.PARTICIPANTSSeventy-seven internal medicine residents at the University of California San Francisco at three continuity clinic sites participated in the study.APPROACHQualitative interviews were audiotaped and transcribed. The authors used a general inductive approach with sensitizing concepts in four frames (structural, human resources, political and symbolic) to develop codes and identify themes.KEY RESULTSResidents believed that team-based care improves continuity and quality of care. Factors in four frames affected their ability to achieve these goals. Structural factors included communication through the electronic medical record, consistent schedules and regular team meetings. Human resources factors included the presence of stable teams and clear roles. Political and symbolic factors negatively impacted team-based care, and included low staffing ratios and a culture of ultimate resident responsibility, respectively. Regardless of the presence of these factors or resident perceptions of their teams, residents did not see the practice of interprofessional team-based care as intrinsically educational.CONCLUSIONSResidents’ experiences practicing team-based care are influenced by many principles described in the interprofessional teamwork literature, including understanding team members’ roles, good communication and sufficient staffing. However, these attributes are not correlated with residents’ perceptions of the educational value of team-based care. Including residents in interprofessional teams in their clinic may not be sufficient to teach residents how team-based care can enhance their overall learning and future practice.

Teaching chronic disease management to interdisciplinary medical learners.

During the month-long elective, students from Canadian, Israeli, Jordanian and Palestinian medical schools come together through an international nongovernment organisation in Canada. Student selection is based on their academic interests in the subtheme and their willingness to work collaboratively with students from other cultures and academic disciplines. Why the idea was necessary The elective programme is unique among educational opportunities offered to health-care students. As a project developed by students for students, it is distinctively positioned to respond to student academic interests. The community service component of the curriculum allows participants to ground their academic learning with hands-on experience in an applied setting. The multidisciplinary academic and social programming provides rare opportunities for Middle Eastern and Canadian students to work together on common health goals, while nurturing a spirit of peace, co-operation and mutual understanding. This approach allows participants to develop practical interdisciplinary collaborative skills essential to understanding and addressing complex global health problems. What was done The 2003 and 2004 programmes focused on paediatric oncology and congenital hearing loss, respectively. The 4-week curriculum consisted of presentations from academic and community leaders, problem-based learning cases, discussion groups and experiential learning in the community. Participants took initiative in researching important health literature collaboratively and presenting these findings to the programme stakeholders. The programme also included team-building activities to encourage the development of personal and professional relationships among the students. Each programme was evaluated using qualitative research methods, which have contributed towards improving future curricula. Evaluation of the results and impact An important academic outcome related by participants was an improved understanding of diverse child health issues. Moreover, the students evaluated the multidisciplinary focus, the community service component and the opportunity for cross-cultural co-operation as highlights of the programme. The experience fostered strong relationships between participants from communities affected by conflict; these connections have persisted and encouraged the development of new health for peace initiatives. The unique experience of transcending political boundaries to explore an important health issue is best explained by a participant of the 2004 programme on congenital hearing loss: ‘What we learned most of all was about our own ‘‘deafness’’ and how we can better listen to each other and cooperate to address common medical problems in the Middle East’.

Faculty development efforts to promote screening, brief intervention, and referral to treatment (SBIRT) in an internal medicine faculty-resident practice

BACKGROUND Screening, brief intervention, and referral to treatment (SBIRT) is a practical means to address substance misuse in primary care. Important barriers to implementing SBIRT include adequacy of training and provider confidence as well as logistical hurdles and time constraints. A faculty development initiative aimed at increasing SBIRT knowledge and treatment of substance use disorders (SUDs) should lead to increased use of SBIRT by faculty and the residents they teach. This study examined how a faculty development program to promote SBIRT influenced faculty practice and resident teaching. METHODS This was a cross-sectional study of faculty exposed to multiple SBIRT educational interventions over a 5-year period in an academic faculty-resident general medicine practice. Participants completed a brief online survey followed by a semistructured interview. Quantitative responses were examined descriptively. Qualitative questions were reviewed to identify key themes. RESULTS Fifteen of 29 faculty (52%) completed the survey and 13 (45%) completed the interviews regarding faculty development interventions. Faculty thought that SBIRT was an important skill and had confidence in screening for substance use disorders, although confidence in making treatment referrals and prescribing pharmacotherapy were rated lower. Many faculty reported screening more frequently for SUDs after attending faculty development sessions. However, several reported that the training did not improve their SBIRT teaching to residents during clinic precepting sessions. To improve uptake of SBIRT, a majority of faculty recommended electronic health record (EHR) alerts. CONCLUSIONS SBIRT is a highly valued set of skills, and training may enhance rates of screening for substance misuse. However, participants did not report a substantial change in SBIRT teaching as a result of faculty development. In the future, small, targeted faculty development sessions, potentially involving strategies for using the electronic health record (EHR), may be an effective way to enhance primary care SBIRT skills.

Continuity Clinic Model and Diabetic Outcomes in Internal Medicine Residencies: Findings of the Educational Innovations Project Ambulatory Collaborative.

BACKGROUND Efforts to improve diabetes care in residency programs are ongoing and in the midst of continuity clinic redesign at many institutions. While there appears to be a link between resident continuity and improvement in glycemic control for diabetic patients, it is uncertain whether clinic structure affects quality measures and patient outcomes. METHODS This multi-institutional, cross-sectional study included 12 internal medicine programs. Three outcomes (glycemic control, blood pressure control, and achievement of target low-density lipoprotein [LDL]) and 2 process measures (A1C and LDL measurement) were reported for diabetic patients. Traditional, block, and combination clinic models were compared using analysis of covariance (ANCOVA). Analysis was adjusted for continuity, utilization, workload, and panel size. RESULTS No significant differences were found in glycemic control across clinic models (P = .06). The percentage of diabetic patients with LDL < 100 mg/dL was 60% in block, compared to 54.9% and 55% in traditional and combination models (P = .006). The percentage of diabetic patients with blood pressure < 130/80 mmHg was 48.4% in block, compared to 36.7% and 36.9% in other models (P < .001). The percentage of diabetic patients with HbA1C measured was 92.1% in block compared to 75.2% and 82.1% in other models (P < .001). Also, the percentage of diabetic patients with LDL measured was significantly different across all groups, with 91.2% in traditional, 70.4% in combination, and 83.3% in block model programs (P < .001). CONCLUSIONS While high scores on diabetic quality measures are achievable in any clinic model, the block model design was associated with better performance.