Kimberly G. Hoffman

Problem-based learning outcomes: ten years of experience at the University of Missouri-Columbia School of Medicine.

Purpose To add to a previous publication from the University of Missouri—Columbia School of Medicine (UMCSOM) on students’ improvement in United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores after the implementation of a problem-based learning (PBL) curriculum by studying the performance of ten PBL class cohorts at the UMCSOM. Method Characteristics of graduating classes matriculating in both traditional and PBL curricula, 1993–2006, were compared for Medical College Admission Test component scores, undergraduate grade point averages, performance on the USMLE Step 1 and Step 2 exams, faculty contact hours, and residency directors’ evaluations of UMCSOM graduates’ performance in the first year of residency. Results Mean scores of six of the ten comparisons for USMLE Step 1 and six of nine comparisons for USMLE Step 2 are significantly higher (p < .01) for UMCSOM PBL students than for first-time examinees nationally. These differences cannot be accounted for by preselection of academically advantaged students, increased time on task, or reduced class size. Gains in performance continue into residency, as evidenced by program directors’ perceptions of superior performance of UMCSOM PBL graduates. Conclusions The PBL curricular changes implemented with the graduating class of 1997 resulted in higher performances on USMLEs and improved evaluations from residency program directors. These changes better prepare graduates with knowledge and skills needed to practice within a complex health care system. Outcomes reported here support the investment of financial and human resources in our PBL curriculum.

Contextual tensions of the clinical environment and their influence on teaching and learning

Background  Academic medical centres face major challenges, and finding creative, effective strategies to support patient care and teaching are critical for survival. At the centre of these challenges is clinical teaching.

Exemplary care and learning sites: linking the continual improvement of learning and the continual improvement of care.

Exemplary care and learning sites : Linking the continual improvement of learning and the continual improvement of care

Exemplary Care and Learning Sites: A Model for Achieving Continual Improvement in Care and Learning in the Clinical Setting

Problem Current models of health care quality improvement do not explicitly describe the role of health professions education. The authors propose the Exemplary Care and Learning Site (ECLS) model as an approach to achieving continual improvement in care and learning in the clinical setting. Approach From 2008–2012, an iterative, interactive process was used to develop the ECLS model and its core elements—patients and families informing process changes; trainees engaging both in care and the improvement of care; leaders knowing, valuing, and practicing improvement; data transforming into useful information; and health professionals competently engaging both in care improvement and teaching about care improvement. In 2012–2013, a three-part feasibility test of the model, including a site self-assessment, an independent review of each site’s ratings, and implementation case stories, was conducted at six clinical teaching sites (in the United States and Sweden). Outcomes Site leaders reported the ECLS model provided a systematic approach toward improving patient (and population) outcomes, system performance, and professional development. Most sites found it challenging to incorporate the patients and families element. The trainee element was strong at four sites. The leadership and data elements were self-assessed as the most fully developed. The health professionals element exhibited the greatest variability across sites. Next Steps The next test of the model should be prospective, linked to clinical and educa tional outcomes, to evaluate whether it helps care delivery teams, educators, and patients and families take action to achieve better patient (and population) outcomes, system performance, and professional development.

What criteria do faculty use when rating students as potential house officers

Third-year medical students’ grades are a combination of faculty observations, National Board of Medical Examiners examinations, and other departmental specific course requirements. Faculty evaluations include assessment of students’ clinical skills, and a global rating for potential as house officer. We wished to better understand the ‘potential as house officer’ and to understand if these competencies were shared across the third year or unique to a given discipline. We then examined the relationship between house officer potential and performance on traditional measures of success. We analyzed the narrative comments from faculty evaluations of third-year students who faculty rated as ‘Outstanding’ in the house officer potential category. The low correlations found between house officer potential and traditional measures of academic success indicate that items beyond the stated learning objectives are influencing faculty evaluation of clinical students. Our data suggest that the awarding of ‘potential for house officer’ reflects the students ability to work as part of a health care team. Although there appear to be common elements among the house officer comments, we also observed discipline specific differences. Given the importance placed on house officer potential, more conversation is needed to develop a common language across the third-year courses.

University of Missouri School of Medicine in Columbia.

The Bylaws of the School of Medicine at the University of Missouri School of Medicine (MU SOM) charge the Curriculum Board with the primary policy-making authority for medical student academic programs. Voting members of the curriculum board are elected from the faculty. Each medical student class elects a nonvoting representative. Dean’s office representatives are ex-officio members. The Preclerkship Curriculum Steering Committee oversees the Year 1–2 curriculum; the Clinical Curriculum Steering Committee oversees Years 3 and 4. Both of these groups report to the Curriculum Board.

Through patient eyes: Can third-year medical students deliver the care patients expect?

Abstract Introduction: Patient-centered approaches have a positive impact on adherence to treatment, self-management of chronic disease, and patient satisfaction. We seek to graduate physicians who provide effective Patient-Centered Care (PCC). The aims of this research were to (a) include the patients’ perspectives in describing behaviors essential to effective PCC, (b) create an authentic, credible tool to assess these behaviors in third-year medical students, and (c) validate the assessment tool through the eyes of our patients. Methods: To develop and validate PCC behaviors we (a) developed PCC descriptors that included patient perspectives, (b) developed scenarios for students to demonstrate PCC, (c) administered the PCC-Objective Structured Clinical Exam, and (d) used the patient perspective to validate results. Results: Faculty and students found the PCC-OSCE to be an authentic experience. Students received abundant individualized feedback and demonstrated strong performance in communicating effectively, avoiding medical jargon, listening actively, demonstrating empathy, and leading critical conversations. Patient critiques of exemplary performances confirmed that the PCC-OSCE assesses elements the patients viewed as essential to PCC. Conclusion: Incorporating the patients’ perspective aids in better understanding professional competencies and legitimizes the assessment.

What Can a Brief Narrative Exercise Reveal About Medical Students’ Development as Patient-Centered Physicians and Their Attitudes Toward Patients with Mental Illness?

The graduation of physicians who have the ability to provide patient-centered care is the central educational goal of the University of Missouri School of Medicine. Its definition of patient-centered care emphasizes delivery of care that respects individual’s perspective [1, 2], shares information, engages the patient in the process of care, and partners with the patient. Teaching patient-centered care is not easy, however [3]. Research has repeatedly demonstrated a decline in altruism and idealism and a growth in cynicism as students progress through medical school [4, 5]. These changes are counterproductive to patient-centered engagement. A disconnection between the ideals taught in the formal curriculum and the behaviors observed in the “hidden curriculum” is particularly problematic [3]. This gap between the ideal and observed is likely to be especially pointed when a patient has a diagnosis that carries stigma, such as mental illness. Research demonstrates that “people with mental illness receive worse treatment for physical disorders... medical staff, guided by negative stereotypes, tend to systematically treat the physical illness of people with mental illness less thoroughly and less effectively” [6]. Widely held negative stereotypes about people with mental illness may be shared by medical students [6, 7]. If such attitudes are not confronted, medical students of today may perpetuate the provision of inadequate (and almost certainly not patient-centered) care. Educational strategies to change medical students’ knowledge, attitudes, and behaviors regarding patients with mental illness include incorporating patient testimonies in lectures, role play, self-directed learning, non-interactive video, and visits to patients in non-medical environments [8, 9]. The outcomes of these interventions vary greatly, but successful education for patient-centered care obliges educators to address bias and stigma. Several authors have advocated for storytelling and other narrative approaches in medical education. Extant literature [10, 11] describes the use of writing exercises to (1) teach content,( 2) enhance personal and professional development, (3) motivate learning, and (4) develop communicative and relational skills, particularly empathy. The last of these is of particular interest, because a key aspect of delivering patient-centered care is first to understand a patient’s unique circumstances (including culture, family circumstance, past experiences) and what he or she considers important or concerning. In this study, students completed a narrative exercise after interviewing an individual with mental illness. The exercise gave the students an opportunity to consider another person’s perspective in relation to the physician. This study reports on the outcomes of a qualitative analysis of the student narratives. The aims of the study were to explore students’ perceptions of what might concern an individual with mental illness who is visiting a physician for non-psychiatric reasons and to consider how their perceptions relate to their ability to provide patient-centered care.

Online lecture capturing system: Expected and actual effects of implementation in a problem-based learning medical curriculum.

Abstract Context: An online lecture capturing system (OLCS) was implemented in a medical school integrating problem-based learning curriculum. An academic investigation examining how medical students used OLCS and what were its educational effects were required. Aims: This study examined medical students’ perceptions of OLCS, actual usage of OLCS, and the effects on learning. Methods: An online questionnaire asking about the perceptions of OLCS was distributed to first and second year medical students. Individual student’s OLCS usage was analyzed descriptively. Cluster analysis was conducted based on the OLCS usage and students’ prior academic performance to reveal the academic effects of OLCS. Results: Most students (82 out of 106) perceived OLCS as an effective educational tool. Their actual use of OLCS, however, was low and quite variable depending on their needs and preferences. Reviewing the captured lectures did not affect students’ performance on exams of knowledge. Conclusions: This study calls for follow-up studies investigating personalized use of OLCS and student attributes in PBL.

Listening to Patients’ Voices: Workarounds Patients Use to Construct Pain Intensity Ratings:

This study analyzed patients’ perspectives about a measure of current, usual, and extreme pain and a measure of activity-related pain. Thirty-one patients with osteoarthritis participated in focus groups. Researchers completed thematic analysis of transcripts using coding software and an inductive approach. Three emerging themes were that many factors affected patients’ perceptions and ratings of pain intensity, patients used different approaches to construct pain ratings, and patients interpreted maximal response anchors differently. Particularly, novel findings were that patients evaluated pain fluctuation, location, duration, and quality when constructing pain intensity ratings. Also, activity items helped patients to remember pain and provided a valued context for communicating pain experiences. However, the activities needed to be sufficiently described and personally relevant. These findings further clarify the challenges patients face and the workarounds they use when rating pain intensity. The patients’ suggestions for improved administration methods and items warrant future investigation.