Kristi J. Ferguson

Teaching Medical Students and Residents Skills for Delivering Bad News: A Review of Strategies

Although delivering bad news is something that occurs daily in most medical practices, the majority of clinicians have not received formal training in this essential and important communication task. A variety of models are currently being used in medical education to teach skills for delivering bad news. The goals of this article are (1) to describe these available models, including their advantages and disadvantages and evaluations of their effectiveness; and (2) to serve as a guide to medical educators who are initiating or refining curriculum for medical students and residents. Based on a review of the literature and the authors’ own experiences, they conclude that curricular efforts to teach these skills should include multiple sessions and opportunities for demonstration, reflection, discussion, practice, and feedback.

Percutaneous Injury, Blood Exposure, and Adherence to Standard Precautions: Are Hospital-Based Health Care Providers Still at Risk?

To examine factors associated with blood exposure and percutaneous injury among health care workers, we assessed occupational risk factors, compliance with standard precautions, frequency of exposure, and reporting in a stratified random sample of 5123 physicians, nurses, and medical technologists working in Iowa community hospitals. Of these, 3223 (63%) participated. Mean rates of hand washing (32%-54%), avoiding needle recapping (29%-70%), and underreporting sharps injuries (22%-62%; overall, 32%) varied by occupation (P<.01). Logistic regression was used to estimate the adjusted odds of percutaneous injury (aOR(injury)), which increased 2%-3% for each sharp handled in a typical week. The overall aOR(injury) for never recapping needles was 0.74 (95% CI, 0.60-0.91). Any recent blood contact, a measure of consistent use of barrier precautions, had an overall aOR(injury) of 1.57 (95% CI, 1.32-1.86); among physicians, the aOR(injury) was 2.18 (95% CI, 1.34-3.54). Adherence to standard precautions was found to be suboptimal. Underreporting was found to be common. Percutaneous injury and mucocutaneous blood exposure are related to frequency of sharps handling and inversely related to routine standard-precaution compliance. New strategies for preventing exposures, training, and monitoring adherence are needed.

The integrated curriculum in medical education: AMEE Guide No. 96

Abstract The popularity of the term “integrated curriculum” has grown immensely in medical education over the last two decades, but what does this term mean and how do we go about its design, implementation, and evaluation? Definitions and application of the term vary greatly in the literature, spanning from the integration of content within a single lecture to the integration of a medical schools comprehensive curriculum. Taking into account the integrated curriculums historic and evolving base of knowledge and theory, its support from many national medical education organizations, and the ever-increasing body of published examples, we deem it necessary to present a guide to review and promote further development of the integrated curriculum movement in medical education with an international perspective. We introduce the history and theory behind integration and provide theoretical models alongside published examples of common variations of an integrated curriculum. In addition, we identify three areas of particular need when developing an ideal integrated curriculum, leading us to propose the use of a new, clarified definition of “integrated curriculum”, and offer a review of strategies to evaluate the impact of an integrated curriculum on the learner. This Guide is presented to assist educators in the design, implementation, and evaluation of a thoroughly integrated medical school curriculum.

Critical Incidents of Nonadherence with Standard Precautions Guidelines Among Community Hospital‐based Health Care Workers

AbstractOBJECTIVE: To identify, categorize, and assess critical incidents of nonadherence to standard precautions. DESIGN: Qualitative and quantitative analysis of a written, mail-out survey. SETTING: Community hospitals. PARTICIPANTS: Statewide stratified random sample of community hospital-based health care workers at risk for blood exposure. MAIN VARIABLE: Responses to the question: “Think of an incident during the past year when you didn’t adhere to universal precautions. Please describe the situation and why you didn’t adhere.” RESULTS: Reasons given for not using precautions included: belief that stopping to use standard precautions would have put the patient at risk (22%); using precautions would have interfered with patient care (20%); precautions were not warranted in a specific situation (14%); did not anticipate the potential for exposure (14%); and high job demands that had caused respondent to be in a hurry (11%). Less often, equipment was not available (7%), respondent forgot (6%), respondent thought that the patient did not pose a risk (4%), or the available equipment was not effective (3%). In terms of overall exposure rates, 34% of those who described an incident had experienced a sharps injury during the previous 3 months and 42% had experienced a mucocutaneous exposure. In terms of overall nonadherence, 44% wore gloves less than 100% of the time, while 61% washed their hands less than 100% of the time.Needlestick injuries were lowest among those who had forgotten to use precautions, while mucocutaneous exposures were highest among those who had not anticipated potential exposure while performing the task. Failure to wear gloves routinely was highest among those who said that following precautions interfered with their ability to provide care and among those who believed a particular patient to be low risk; failure to wash hands routinely was also highest among the latter group and lowest among those who said necessary equipment was not available. CONCLUSIONS: Using specific information about local incidents of nonadherence to standard precautions may enhance training, especially if the program identifies incidents of unanticipated exposure and helps workers plan for them in the future. Closer examination of job demands and responsibilities that interfere with standard precautions may increase the likelihood of adherence.

FAMILY SUPPORT, HEALTH BELIEFS, AND THERAPEUTIC COMPLIANCE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Abstract Compliance with recommendations about aspirin, exercise, and splints was evaluated in 40 patients with rheumatoid arthritis to determine the relationship of compliance to two variables: family support and belief in benefit. Interventions to enhance family support were effective in two cases, but belief in the benefit of the recommendation was the critical variable in all types of compliance.

Predictors of Hepatitis B Vaccine Acceptance in Health Care Workers

This article examines the relative importance of occupational, epidemiologic, and attitudinal factors in hepatitis B vaccine acceptance. A stratified random sample of 1,018 health care workers at risk for occupational blood exposure at our university hospital were contacted in 1992 and 919 (90%) participated. Potential reasons for vaccine acceptance or refusal were evaluated with factor analysis. Logistic regression models were calibrated on a stratified random subsample to identify independent predictors of initiating and completing the series, then validated on the remaining subjects. Fifty-four percent (482 of 898) of previously nonimmune workers had completed the series, while 70% (626) had received one or more doses. Hepatitis B vaccine acceptance was related strongly to social influence (physicians, supervisors, role models, friends, and spouse) and knowledge of the disease and vaccine, whereas refusal was primarily related to concern about vaccine side effects and problems with vaccine access. Independent predictors of initiating the vaccine series included younger age (odds ratio [OR] 0.98 per year, 95% confidence interval [CI95] 0.96-0.997), occupation (housestaff: OR 2.9, CI95 1.1-7.9; nurses: OR 2.1, CI95 1.0-4.3 versus housekeepers), increased blood exposure frequency (OR 2.4, CI95 1.6-3.5 for 1-6 versus 0 exposures in past year), and increased frequency of recent influenza vaccination (OR 3.3, CI95 2.0-5.3 for 1 versus 0 doses in prior 3 years). Occupation (increased acceptance among housestaff, nurses, nursing assistants, laboratory technicians), increased frequency of blood exposure, and recent influenza vaccination also were predictors of series completion. Factors such as occupation, blood exposure frequency and acceptance of other preventive services may help identify health care worker groups with low vaccine acceptance most likely to benefit from targeted vaccine delivery. Hepatitis B vaccine should be offered routinely during evaluation for occupational blood exposure. Future vaccine implementation efforts should emphasize the involvement of physicians and supervisors and education about occupational disease risk, liability, and the safety of the vaccine.

Evaluating the usefulness of computerized adaptive testing for medical in-course assessment.

PURPOSE This study investigated the feasibility of converting an existing computer-administered, in-course internal medicine test to an adaptive format. METHOD A 200-item internal medicine extended matching test was used for this research. Parameters were estimated with commercially available software with responses from 621 examinees. A specially developed simulation program was used to retrospectively estimate the efficiency of the computer-adaptive exam format. RESULTS It was found that the average test length could be shortened by almost half with measurement precision approximately equal to that of the full 200-item paper-and-pencil test. However, computer-adaptive testing with this item bank provided little advantage for examinees at the upper end of the ability continuum. An examination of classical item statistics and IRT item statistics suggested that adding more difficult items might extend the advantage to this group of examinees. CONCLUSIONS Medical item banks presently used for incourse assessment might be advantageously employed in adaptive testing. However, it is important to evaluate the match between the items and the measurement objective of the test before implementing this format.

Defining and Describing Medical Learning Communities: Results of a National Survey

Purpose To investigate what is meant by learning community in medical education and to identify the most important features of current medical education learning communities. Method After a literature review, the authors surveyed academic deans of all U.S. and Canadian medical schools and colleges (N = 124) to identify those that had implemented a learning community. Those with student learning communities (N = 18) answered a series of questions about the goals, structure, function, benefits, and challenges of their communities. Results The most common primary goals included fostering communication among students and faculty; promoting caring, trust, and teamwork; helping students establish academic support networks; and helping students establish social support networks. Most deans said that students remained in the same community for all four years of medical school and that communities were linked to specific faculty and/or peer advisors. For most schools, communities included students from many class years, and participation was mandatory. Curricular purposes included professionalism training, leadership development, and service learning. Almost all schools had social functions related to their communities, and most provided career planning, group mentoring, and personal counseling. Conclusions Learning communities in medical education demonstrate diverse approaches to achieving the general goal of enhanced student learning. Medical school leaders considering learning communities should determine the goals they want to accomplish and be open to adopting different approaches based on local needs. Evaluation and effective monitoring of evolution are needed to determine the best approaches for different needs and to assess impact on students and faculty.

Academic Physicians and Complementary and Alternative Medicine: An Institutional Survey:

In order to assess attitudes, awareness, and behavior related to complementary and alternative medicine (CAM) among academic physicians, a questionnaire study was conducted with faculty in one of the largest teaching hospitals in the United States. The survey assessed attitudes toward and awareness of 11 CAM therapies in regard to patient usage and usefulness. The majority of respondents believed that only 20% or less of their patients used CAM. Respondents varied widely on level of knowledge/awareness of specific CAM therapies. Those who were more knowledgeable were more likely to perceive CAM as useful and to have recommended more therapies. The modalities respondents noted as knowing the least about were deemed the least useful. Limited knowledge of most CAM therapies and limited awareness of patient CAM use points to the need for continuing education efforts for physicians, focusing on CAM.

Medical students' perceptions of emerging learning communities at one medical school.

Purpose In 1999, the University of Iowa Roy J. and Lucille A. Carver College of Medicine (UICCOM) established a student management model consisting of four student-style learning communities (LCs), each comprising one quarter of the students from each class, with the goal of fostering student connection, excellence, learning, leadership, and service. The authors present results of a prospective evaluation of medical students’ perceptions of emerging LCs and their impact on medical student life at UICCOM. Method A two-page questionnaire, administered in 1999 and again in 2003 to all second-through fourth-year and MD/PhD students, assessed connections among students from different years of study, students’ participation in activities, anticipated/perceived benefits of LCs, concerns about LCs, and the impact of LCs on students’ perceptions of the learning environment. Questions were open ended or Likert scaled; statistical analyses were descriptive, parametric, and nonparametric. Results Comparison of results between 1999 and 2003 demonstrated increased connections between students and participation in LC activities, positive perceptions of the overall learning environment, increased access to faculty and staff, and increased involvement in leadership and service activities. Student concerns included continued obstacles to involvement in LCs for third- and fourth-year students. Conclusions This prospective evaluation demonstrates that LCs can contribute to more positive perceptions of the learning environment and increased interaction between students throughout medical school. LCs seem to increase student leadership development and engagement in the broader community. Further investigation is needed to determine how these potential benefits of LCs can be maximized and made more accessible to all students.