Kathleen Hanley

Measuring the competence of residents as teachers.

Medical residents, frontline clinical educators, must be competent teachers. Typically, resident teaching competence is not assessed through any other means than gleaning learner’s comments. We developed, evaluated, and integrated into our annual objective structured clinical examination a resident teaching skills assessment using “standardized” students. Faculty observers rated residents using a customized 19-item rating instrument developed to assess teaching competencies that were identified and defined as part of our project. This was feasible, acceptable, and valuable to all 65 residents, 8 students, and 16 faculty who participated. Teaching scenarios have potential as reliable, valid, and practical measures of resident teaching skills.

Extended-release naltrexone for treatment of alcohol dependence in primary care

The feasibility of using extended-release injectable naltrexone (XR-NTX) to treat alcohol dependence in routine primary care settings is unknown. An open-label, observational cohort study evaluated 3-month treatment retention, patient satisfaction, and alcohol use among alcohol-dependent patients in two urban public hospital medical clinics. Adults seeking treatment were offered monthly medical management (MM) and three XR-NTX injections (380 mg, intramuscular). Physician-delivered MM emphasized alcohol abstinence, medication effects, and accessing mutual help and counseling resources. Seventy-two alcohol-dependent patients were enrolled; 90% (65 of 72) of eligible subjects received the first XR-NTX injection; 75% (49 of 65) initiating treatment received the second XR-NTX injection; 62% (40 of 65), the third. Among the 56% (n = 40) receiving three injections, median drinks per day decreased from 4.1 (95% confidence interval = 2.9-6) at baseline to 0.5 (0-1.7) during Month 3. Extended-release naltrexone delivered in a primary care MM model appears a feasible and acceptable treatment for alcohol dependence.

''Oh! She Doesn't Speak English!'' Assessing Resident Competence in Managing Linguistic and Cultural Barriers

AbstractBACKGROUND: Residents must master complex skills to care for culturally and linguistically diverse patients. METHODS: As part of an annual 10-station, standardized patient (SP) examination, medical residents interacted with a 50-year-old reserved, Bengali-speaking woman (SP) with a positive fecal occult blood accompanied by her bilingual brother (standardized interpreter (SI)). While the resident addressed the need for a colonoscopy, the SI did not translate word for word unless directed to, questioned medical terms, and was reluctant to tell the SP frightening information. The SP/SI, faculty observers, and the resident assessed the performance. RESULTS: Seventy-six residents participated. Mean faculty ratings (9-point scale) were as follows: overall 6.0, communication 6.0, knowledge 6.3. Mean SP/SI ratings (3.1, range 1.9 to 3.9) correlated with faculty ratings (overall r=.719, communication r=.639, knowledge r=.457, all P<.01). Internal reliability as measured by Cronbach’s α coefficients for the 20 item instrument was 0.91. Poor performance on this station was associated with poor performance on other stations. Eighty-nine percent of residents stated that the educational value was moderate to high. CONCLUSION: We reliably assessed residents communication skills conducting a common clincal task across a significant language barrier. This medical education innovation provides the first steps to measuring interpreter facilitated skills in residency training.

Teaching physicians to address unhealthy alcohol use: A randomized controlled trial assessing the effect of a Web-based module on medical student performance

BACKGROUND The authors developed and evaluated an interactive, Web-based module to train medical students in screening and brief intervention (SBI) for unhealthy alcohol use. METHODS First-year students were randomized to module versus lecture. Change in knowledge, attitudes, and confidence were compared. Performance was assessed by objective structured clinical examination (OSCE) and analyzed by intention to treat and treatment received. RESULTS Of 141 consenting students, 64% (n = 90) completed an intervention (54% lecture vs. 70% Web assigned). Knowledge, confidence, and attitudes improved in both groups, with more improvement in Advise-Assist knowledge for Web students (14% vs. -3%, p = .003). Web students outperformed their lecture peers in both general communication (65% vs. 51% items well done, p = .004) and alcohol-specific tasks (54% vs. 41%, p = .021) on OSCE. Analysis by treatment received enhanced between-group differences. CONCLUSION Use of a Web-based module to teach SBI is associated with greater knowledge gain and skills performance compared with a lecture covering similar content. The module provides an efficient means for training in this area.

Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system

BackgroundWhile unannounced standardized patients (USPs) have been used to assess physicians’ clinical skills in the ambulatory setting, they can also provide valuable information on patients’ experience of the health care setting beyond the physician encounter. This paper explores the use of USPs as a methodology for evaluating patient-centered care in the health care system.MethodsUSPs were trained to complete a behaviorally-anchored assessment of core dimensions of patient-centered care delivered within the clinical microsystem, including: 1) Medical assistants’ safe practices, quality of care, and responsiveness to patients; 2) ease of clinic navigation; and 3) the patient-centeredness of care provided by the physician. Descriptive data is provided on these three levels of patient-centeredness within the targeted clinical microsystem. Chi-square analyses were used to signal whether variations by teams within the clinical microsystem were likely to be due to chance or might reflect true differences in patient-centeredness of specific teams.ResultsSixty USP visits to 11 Primary Care teams were performed over an eight-month period (mean 5 visits/team; range 2–8). No medical assistants reported detecting an USP during the study period. USPs found the clinic easy to navigate and that teams were functioning well in 60% of visits. In 30% to 47% of visits, the physicians could have been more patient-centered. Medical assistants’ patient safety measures were poor: patient identity was confirmed in only 5% of visits and no USPs observed medical assistants wash their hands. Quality of care was relatively high for vital signs (e.g. blood pressure, weight and height), but low for depression screening, occurring in only 15% of visits. In most visits, medical assistants greeted the patient in a timely fashion but took time to fully explain matters in less than half of the visits and rarely introduced themselves. Physicians tried to help patients navigate the system in 62% of visits.ConclusionsUSP assessment captured actionable, critical, behaviorally-specific information on team and system performance in an urban community clinic. This methodology provides unique insight into the patient-centeredness and quality of care in medical settings.

Objective structured clinical examinations

Objective structured clinical examinations : , Objective structured clinical examinations : , کتابخانه دیجیتال جندی شاپور اهواز

'We might as well be speaking different languages': an innovative interprofessional education tool to teach and assess communication skills critical to patient safety

Introduction All practicing health professionals must be able to communicate effectively with their colleagues around the care of patients. Better communication between health professionals not only improves patient outcomes, but also cuts down on costly and unnecessary tests or healthcare services. At New York University (NYU), we have addressed the need for interprofessional education (IPE) by incorporating a set of interprofessional objective structured clinical examinations (OSCEs) cases into our performance-based assessment programme to expand the educational tools for interprofessional collaborative (IPC) practice, assessment and feedback. Methods We identified and operationalised IPC competencies to create an assessment tool for use in IPC clinical cases, delineating core domains and then identifying observable behaviours that represented the broader competencies. IPC cases (for use in OSCEs) were designed in a way that required medical students and residents to collaborate effectively with a health professional from another discipline (standardised registered nurse (RN)) in order to provide quality care to a (standardised) patient. Feedback from the standardised RN and the participants was content analysed and our own experience in implementing was described. Results This method demonstrates that IPC practice can effectively be incorporated into medical education training and assessment, at the undergraduate and graduate level. We found high internal consistency among items within each of the core IPC competency domains (Cronbachs α 0.80–0.85). Based on both standardised RN and faculty feedback, the cases were effective in discriminating among learners within and across undergraduate medical education (UME) and graduate medical education (GME) levels, and within learners, in identifying individual strengths and weaknesses. Learners found these cases to be realistic, challenging and stimulating. Conclusions OSCE-based IPC training is a feasible and useful methodology. Ultimately, IPC OSCE cases are training tools that provide learners with a safe environment to practice, receive feedback and develop the critical skills needed for our evolving healthcare system. The next steps are to expand the scope of IPE cases to include more team members, and team work to also incorporate faculty development to ensure that our teachers and role models are effective in providing feedback on IPC practice.

Self-assessment and goal-setting is associated with an improvement in interviewing skills

Purpose Describe the relationship between medical students’ self-assessment and goal-setting (SAGS) skills and development of interviewing skills during the first-year doctoring course. Method 157 first-year medical students completed three two-case standardized patient (SP) interviews. After each of the first two, students viewed videotapes of their interview, completed a SAGS worksheet, and reviewed a selected tape segment in a seminar. SAGS was categorized into good and poor quality and interviewing skills were rated by trained raters. Results SAGS improved over time (37% good week 1 vs. 61% good week 10). Baseline SAGS and interviewing skills were not associated. Initial SAGS quality was associated with change in interviewing skills – those with poor-quality SAGS demonstrated a decrease and those with good-quality SAGS demonstrated an increase in scores by 17 weeks (ANOVA F=4.16, p=0.024). For students whose SAGS skills were good at both week 1 and 10, interviewing skills declined in weeks 1–10 and then increased significantly at week 17. For those whose SAGS remained ‘poor’ in weeks 1–10, interviewing skills declined in weeks 10–17. Conclusions In general, the quality of students’ SAGS improved over time. Poor baseline SAGS skills and failure to improve were associated with a decrease in interviewing skills at 17 weeks. For students with better SAGS, interviewing skills increased at week 17. Improvement in SAGS skills was not associated with improved interviewing skills. Understanding structured self-assessment skills helps identify student characteristics that influence progressive mastery of communication skills and therefore may inform curriculum and remediation tailoring.

Clever Nihilism: Cynicism in Evidence Based Medicine Learners

Abstract Evidence-based medicine (EBM) educators are often confronted with learners who use their new critical appraisal skills to dismiss much of the medical literature. Does this cynical attitude of “clever nihilism” affect educational outcomes, such that educators need to tailor their curricula to these learners? The authors proposed that this critical skepticism may be an intermediate developmental stage for EBM learners as they progress from “naïve empiricism” to “mature pragmatism” and sought to observe its effect on educational outcomes from an intensive, 6 week EBM course. In this course, fifty-four medical residents reported significantly improved skills in critical appraisal and electronic searching. However there was no association between a measure of clever nihilism and the self-reported educational outcomes. The role of clever nihilism in the EBM classroom remains a potentially important issue, and its lack of effect here may be a product of several methodological limitations addressed in the discussion. Such a construct requires further validation The question remains as to whether such cynicism is a learning style or a developmental phase.

Revising residents’ addiction experience: a 1-week intensive course

What problem was addressed? Medical residents are not adequately prepared to address substance use (SU) disorders despite the substantial and increasing contribution to mortality, disability and health care costs. Insufficient training contributes to low levels of confidence and increased frustration. These attitudes and a lack of skills then result in general discomfort and avoidance of counselling and treating patients with SU disorders. What was tried? We developed a week-long intensive course for primary care internal medicine interns (WAM! Week of Addiction Medicine). The curriculum was based in a learner-centred, experiential education model. Interns participated in lectures, patient interviews, a journal club, discussion of the literature on addiction and clinical site visits. Sessions covered neurobiology of addiction, opiates, alcohol, motivational interviewing, brief interventions, harm reduction and policy. Motivational interviewing training included theory, skills-based practice and coaching sessions. We utilised preand post-tests to measure both knowledge and attitudes. The organisation of the week was championed by the chief resident, with support and teaching from core primary care faculty members and addiction specialists. What lessons were learned? Overall, this innovative curriculum on addiction medicine increased knowledge of and improved attitudes towards substance use. The mean test score for clinical knowledge improved from 50% to 70% (p < 0.0005). The mean confidence score increased from 2.7 to 4.2 (p < 0.0005) on a 5-point Likert scale. At baseline, 69% of participants somewhat or strongly agreed that treating SU is rewarding; this increased to 94% at the end of the week. Likewise, 57% somewhat or strongly believed at baseline that they could make a difference for their addicted patients, compared with 88% after the course. Qualitative feedback was strongly positive. We believe that the success of this programme can be attributed to several factors. The consolidated learning during the week allowed a deeper dive into the topic, compared with having multiple experiences spread out over time. We utilised specialists and resources within our medical system and provided myriad experiences through interactive sessions. The learners left the classroom to visit different clinical settings (in-patient detox, intensive out-patient treatment or methadone clinic) to which they could refer patients. We hypothesise that first-hand exposure will lead to a more sustained impact compared with having representatives from those sites come to them, creating an active learning experience. Finally, we believe that incorporating a focus on patients in recovery and outpatient settings was a positive contrast to experiences residents may have had on the in-patient wards, and may have contributed to the increase in positive attitudes towards treating patients with SU. In conclusion, there is a knowledge gap and a pervasive negative attitude towards SU disorders. Knowledge, confidence and attitudes towards SU improved after this intensive week of addiction medicine. Future studies will need to determine if the effects persist and lead to improved physician satisfaction, patient counselling, treatment and health outcomes. There is a possibility that primary care residents have a different level of interest in or baseline motivation to learn about SU. Going forward we will continue to set aside one week each spring for this course. We plan to expand the programme to a larger cohort of trainees.