Kelley M. Skeff

Global health training and international clinical rotations during residency: current status, needs, and opportunities.

Increasing international travel and migration have contributed to globalization of diseases. Physicians today must understand the global burden and epidemiology of diseases, the disparities and inequities in global health systems, and the importance of cross-cultural sensitivity. To meet these needs, resident physicians across all specialties have expressed growing interest in global health training and international clinical rotations. More residents are acquiring international experience, despite inadequate guidance and support from most accreditation organizations and residency programs. Surveys of global health training, including international clinical rotations, highlight the benefits of global health training as well as the need for a more coordinated approach. In particular, international rotations broaden a resident’s medical knowledge, reinforce physical examination skills, and encourage practicing medicine among underserved and multicultural populations. As residents recognize these personal and professional benefits, a strong majority of them seek to gain international clinical experience. In conclusion, with feasible and appropriate administrative steps, all residents can receive global health training and be afforded the accreditation and programmatic support to participate in safe international rotations. The next steps should address accreditation for international rotations and allowance for training away from continuity clinics by residency accreditation bodies, and stipend and travel support for six or more weeks of call-free elective time from residency programs.

Enhancing teaching effectiveness and vitality in the ambulatory setting

ConclusionAmbulatory care faculty are taking on a role of unprecedented importance. Development of methods to assist them in this important role is essential. I have not attempted to include all possible approaches to improve faculty effectiveness and enthusiasm in this paper. Nevertheless, I hope that the framework used in this article will provide a basis for thinking about the roles of ambulatory care faculty and the support system they need to remain effective and enthusiastic. These teachers are important to the changing field of medicine and medical education. They now deserve our attention.Ambulatory care faculty are taking on a role of unprecedented importance. Development of methods to assist them in this important role is essential. I have not attempted to include all possible approaches to improve faculty effectiveness and enthusiasm in this paper. Nevertheless, I hope that the framework used in this article will provide a basis for thinking about the roles of ambulatory care faculty and the support system they need to remain effective and enthusiastic. These teachers are important to the changing field of medicine and medical education. They now deserve our attention.

Faculty Development: A Resource for Clinical Teachers

Clinical teachers have the challenging and profound responsibility to convey the art and science of current medical practice. Fortunately, over the past four decades, a variety of programs have been developed to help them play this difficult role. Starting with the initial work of Miller and colleagues in the mid 1950s,1 faculty-development programs to enhance instructional skills have been created for the large cadre of clinician-educators in this country. Since 1978, the Department of Health and Human Services and foundations such as the Kaiser Family Foundation, the Macy Foundation, and the Robert Wood Johnson Foundation have supported programs that emphasize teaching. Such initiatives have resulted in a wide variety of faculty-development programs operating at the institutional, regional, and national levels. The rationale for providing support for clinician-educators can be found in both the task of clinical teaching itself and the empirical studies of faculty-development programs. The task of teaching in general is complex and difficult.2 Clinical teaching can be especially difficult. First, its intended outcome—the effective training of medical practitioners—imposes a ponderous responsibility on the clinical teacher. In the short term, effective clinical teaching is necessary to provide society with excellent care for patients currently in teaching hospitals. Over the long term, effective clinical teaching provides the underpinnings for the high quality of care given patients away from the academic center, who are treated long after physicians finish their formal training. Second, clinical teaching is laden with many educational challenges requiring a breadth of skills. Clinical teachers are expected to address a wide range of educational goals (knowledge, attitudes, and skills); to work with learners who vary greatly in their experience and abilities (students through fellows); to use a variety of teaching methods (lecturing, small–group discussion, and one-on-one teaching); and to teach in different settings (inpatient, outpatient, and lecture hall).3–5 Moreover, clinical teaching is commonly compounded by the simultaneous requirement to deliver patient care. Given this complexity, clinical teachers need to be prepared with as many teaching skills as possible. Empirical studies provide further evidence for the value of faculty development. First, in evaluating many faculty-development programs, clinical teachers rate the experience as useful, and they recommend their experience to colleagues.6,7 Second, evaluation measures show that such programs can improve teachers’ knowledge, skills, and attitudes. These measures include improvements in the following: self–reported knowledge and the use of educational terms before and after training,8 retrospective ratings of knowledge and skills,9,10 teacher ratings of self-efficacy in teaching specific content,11 teacher behavior during problem-based tutorials,12 teacher beliefs regarding problem-based methods,13 ratings from videotapes of participants’ teaching,3 and attitudes toward collaboration between community faculty and university programs.14 Other unpublished data describe improvements in student ratings,15 participants’ self-report 3 to 6 months after training regarding the concepts and skills taught in the program (T. A. DeWitt and M. Quirk, unpublished results),16 and participants’ ability to use educational concepts when analyzing videotaped teaching scenarios (K. M. Skeff and G. A. Stratos, unpublished results).17 In summary, the difficulty of clinical teaching coupled with the evidence that clinician-educators can improve in this role indicates the value of faculty-development programs. Although this rationale for using faculty-development methods is forceful, most medical faculty still have not participated in programs to improve teaching skills. Possible reasons include barriers to faculty participation and lack of knowledge about resources. To help more faculty benefit from available methods, we shall discuss potential barriers to participation in faculty-development programs, provide a summary of the types of available programs in primary care fields, describe characteristics of effective teaching-improvement methods, and recommend how to choose among teaching-improvement methods.

Evaluation of the seminar method to improve clinical teaching

The effects of a seminar method to improve the teaching of ward attending physicians were evaluated. Forty-six attending physicians from four institutions were randomly assigned to experimental and control groups. The method was evaluated to assess its effects on attending physicians’ performances and attitudes, and impact on learners. Evaluation methods included ratings of videotapes of ward rounds, teachers’ subjective assessments of both their teaching performances and their experiences in the study, and trainee ratings. Videotape ratings, the teachers’ own assessments, and the trainees’ assessments of the attending physicians’ impact on learning were significantly different, favoring the experimental group (p<0.05). It is concluded that the seminar method can provide the basis for effective and feasible approaches for improving clinical teaching by attending physicians.

The Stanford faculty development program: A dissemination approach to faculty development for medical teachers

The Stanford Faculty Development Program, designed to improve the instructional skills of clinical teachers, uses a dissemination model to provide faculty development activities for medical schools across the country. Selected clinical faculty attend a month‐long training program at Stanford University Medical Center and then return to their home institutions to conduct seminars for their fellow faculty and for residents in one of three content areas: (a) principles and skills of clinical teaching, (b) the teaching of medical decision making, or (c) the teaching of clinical preventive medicine. Faculty from institutions affiliated with over one quarter of U.S. medical schools have participated in the program. From 1986 through 1991, the program has trained 67 seminar facilitators from 47 institutions who have then conducted training for over 500 faculty and 200 residents. The extent of dissemination indicates that this approach provides a feasible mechanism for delivering faculty development in a wide var...

Barriers to effective teaching

Medical school faculty members are charged with the critical responsibility of preparing the future physician and medical scientist workforce. Recent reports suggest that medical school curricula have not kept pace with societal needs and that medical schools are graduating students who lack the knowledge and skills needed to practice effectively in the 21st century. The majority of faculty members want to be effective teachers and graduate well-prepared medical students, but multiple and complex factors-curricular, cultural, environmental, and financial-impede their efforts. Curricular impediments to effective teaching include unclear definitions of and disagreement on learning needs, misunderstood or unstated goals and objectives, and curriculum sequencing challenges. Student and faculty attitudes, too few faculty development opportunities, and the lack of an award system for teaching all are major culture-based barriers. Environmental barriers, such as time limitations, the setting, and the physical space in which medical education takes place, and financial barriers, such as limited education budgets, also pose serious challenges to even the most committed teachers. This article delineates the barriers to effective teaching as noted in the literature and recommends action items, some of which are incremental whereas others represent major change. Physicians-in-training, medical faculty, and society are depending on medical education leaders to address these barriers to effect the changes needed to enhance teaching and learning.

The effect of a clinical teaching retreat on residents’ teaching skills

No abstract available.

Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians.

BACKGROUND Cardiac screening in adults with resting or stress electrocardiography, stress echocardiography, or myocardial perfusion imaging can reveal findings associated with increased risk for coronary heart disease events, but inappropriate cardiac testing of low-risk adults has been identified as an important area of overuse by several professional societies. METHODS Narrative review based on published systematic reviews; guidelines; and articles on the yield, benefits, and harms of cardiac screening in low-risk adults. RESULTS Cardiac screening has not been shown to improve patient outcomes. It is also associated with potential harms due to false-positive results because they can lead to subsequent, potentially unnecessary tests and procedures. Cardiac screening is likely to be particularly inefficient in adults at low risk for coronary heart disease given the low prevalence and predictive values of testing in this population and the low likelihood that positive findings will affect treatment decisions. In this patient population, clinicians should focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise. HIGH-VALUE CARE ADVICE Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

Impact of a clinical preventive medicine curriculum for primary care faculty: Results of a dissemination model

BACKGROUND This study was designed to test a dissemination model for providing clinical preventive medicine (CPM) training to general internal medicine faculty across the United States. METHODS The model incorporated direct instruction of a few faculty as seminar facilitators who, in turn, taught a CPM curriculum to their faculty colleagues, who then could teach it to housestaff and students. The CPM curriculum consisted of six seminars that focused primarily on the risk factors for chronic diseases and on behavior change methods for modifying smoking, diet, and exercise. RESULTS Faculty who participated in the seminars had significant pre- to post-test increase in knowledge and reported self-efficacy to implement CPM strategies with patients, as well as changes in CPM clinical practices. These faculty, in turn, successfully disseminated CPM information to their housestaff, who also had increases in self-efficacy and changed clinical practices regarding CPM topics. CONCLUSIONS The successful implementation of the dissemination model attests to its viability as a mechanism for disseminating CPM curricula and increasing the emphasis on CMP issues in both clinical teaching and clinical encounters with patients.

Clinical teaching improvement: The transportability of the Stanford Faculty Development Program.

Background: The Stanford Faculty Development Center (SFDC) at Stanford University developed a teaching improvement course for medical teachers that has been widely disseminated using a train-the-trainer model. We were curious to see if cultural factors might influence the applicability and impact of the course when delivered to non-American participants by a facilitator from that culture. Methods: A Swedish anaesthesiologist at Uppsala University Hospital, Sweden, was trained in October 2004 at Stanford University. From January 2005 to March 2007 he delivered five faculty development seminar series at Uppsala University Hospital to 40 physicians from different departments. Participants rated the usefulness of the seminar series and retrospective pre- and post-seminar ratings were used to assess effects on participants’ teaching skills and behaviours. Results: Participants rated the seminars as highly useful (M = 4.8, SD = 0.4). Participants’ ratings of their teaching ability indicated significant increases across a variety of clinical and non-clinical teaching settings (p < 0.001), and positive changes in teaching behaviours were found for all seven educational categories assessed (p < 0.001). Conclusions: This faculty development model is highly transportable to medical teachers in Sweden, and capable of producing positive results, consistent with those found in the United States.