Lloyd Rucker

Training the clinical eye and mind: using the arts to develop medical students' observational and pattern recognition skills

Introduction  Observation, including identification of key pieces of data, pattern recognition, and interpretation of significance and meaning, is a key element in medical decision making. Clinical observation is taught primarily through preceptor modelling during the all‐important clinical years. No single method exists for communicating these skills, and medical educators have periodically experimented with using arts‐based training to hone observational acuity. The purpose of this qualitative study was to better understand the similarities and differences between arts‐based and clinical teaching approaches to convey observation and pattern recognition skills.

Residents-as-teachers Training in U.s. Residency Programs and Offices of Graduate Medical Education

Resident physicians provide a substantial proportion of the teaching that medical students and junior residents receive, spending numerous hours every week teaching. As stated in the Graduate Medical Education Core Curriculum of the Association of American Medical Colleges (AAMC), residents’ teaching skills are vitally important, particularly for those residents who teach third-year medical students in the so-called ‘‘core clinical clerkships,’’ which traditionally include internal medicine, pediatrics, obstetrics–gynecology, surgery, psychiatry, and family medicine. Although the residency review committee of only one of these specialties (psychiatry) currently mandates residents’ training in teaching skills, the Liaison Committee on Medical Education (LCME) states that residents should ‘‘participate in teaching [clerkship] students’’ and ‘‘be prepared for their roles as teachers and evaluators.’’ Residency programs vary in their teaching-skills training for residents. Bing-You and Tooker found in a 1993 survey of internal medicine residencies that only 20% offered teaching-skills improvement programs for their residents. In most specialties, no published studies have ever documented how many such residents-as-teachers programs exist. To clarify the prevalence and characteristics of residents-as-teachers curricula in U.S. graduate medical education, a group of investigators collaborating with the AAMC’s Section for Graduate Medical Education surveyed directors of residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), as well as deans and directors of offices of graduate medical education (GME) at LCME-accredited medical schools.

Can Poetry Make Better Doctors? Teaching the Humanities and Arts to Medical Students and Residents at the University of California, Irvine, College of Medicine

The Program in Medical Humanities & Arts at the University of California, Irvine, College of Medicine has been in existence for five years. The program was implemented to enhance aspects of professionalism including empathy, altruism, compassion, and caring toward patients, as well as to hone clinical communication and observational skills. It contains elective or required curriculum across all four years of medical school and required curriculum in two residency programs, organized according to structural principles of horizontal coherence, vertical complexity, and patient care applications. The program emphasizes small-group, interdisciplinary teaching and faculty development, and is notable for learners’ use of creative projects to reflect on patients and themselves. Evaluation of the program indicates a positive response among learners. More systematic studies point to increases in empathy and positive attitudes toward the humanities as tools for professional development as a result of exposure to the program curriculum. Future directions include closer collaboration with the University of California, Irvine, Schools of the Arts and Humanities, involvement of local artists and writers, and development of a graduation with distinction in humanities for medical students.

Teaching the art of doctoring: an innovative medical student elective.

The authors describe a longitudinal third- and fourth-year elective, ‘The Art of Doctoring’, introduced in an attempt to counteract perceived frustration and cynicism in medical students at their home institution during the clinical years. The course goals aimed at helping students to develop self-reflective skills; improve awareness of and ability to modify personal attitudes and behaviors that compromise patient care; increase altruism, empathy and compassion toward patients; and sustain commitment to patient care, service and personal well-being. These goals were accomplished through introduction and development of five skill sets: learning from role models and peers; on-site readings of works by medical student- and physician-authors; self- and other-observation; self-reflective techniques; and case-based problem-solving. The course involved regular in-class exercises and homework assignments, as well as a personal project related to improving personal compassion, caring and empathy toward patients. Students also learned to use a coping algorithm to approach problematic clinical and interpersonal situations. Class discussions revealed three issues of recurring importance to students: loss of idealism, non-compliant patients, and indifferent, harsh or otherwise unpleasant attendings and residents. Quantitative and qualitative student evaluations overall indicated a generally favorable response to the course. Problems and barriers included attendance difficulties and variable levels of student engagement. Future directions for this type of educational intervention are considered, as well as its implications for medical education.

An innovative, longitudinal program to teach residents about end-of-life care.

At the University of California, Irvine Medical Center, an end-of-life curriculum was implemented in 2000 for an internal medicine residency utilizing a longitudinal approach that allowed residents to follow patients through their entire hospice experience. An elective home hospice rotation was developed for which third-year residents served as primary care physicians for patients at the end of life over a one-year period. Residents were supervised by faculty who were hospice medical directors. They also learned through case vignettes, quarterly meetings, textbook reading, and personal projects. From July 2000 to June 2002, residents demonstrated positive attitudes towards hospice care and recommended the rotation highly (mean 8.86 on a scale of 1–10). The rotation grew in popularity from six initial residents to ten residents the next year, and has since become a mandatory rotation for all senior residents. A 360-degree evaluation uniformly indicated positive resident performance from the hospice team (mean scores 7.56–8.69 on a 1–9 scale), family (mean scores 9.3–9.7 on a 1–10 scale) and faculty (mean scores 7.29–7.72 on a 1–9 scale). Residents were also pleased with the level of teaching (mean 8.86 on a scale of 1–10) and felt that the patient care load was “just right.” Their knowledge improved by 8% (p = .0175). In conclusion, a longitudinal hospice rotation was implemented that fulfilled curricular goals without undue burden on the residents or residency program.

Access to medical care in a medically indigent population

Objective:To study the nature and extent of barriers to access to medical care in a single county and to define the nature of the illnesses in a population affected by those barriers.Design:Descriptive study of consecutive patients not able to obtain medical care because of financial or other barriers. Financial barriers and medical diagnoses were categorized and the severity of illness and impact of unavailability of medical services were judged by a panel of internists using consensus analysis. The likelihood of obtaining care after refusal of assistance was also evaluated.Setting:A social services eligibility office on the grounds of an urban, university teaching hospital that serves a largely medically indigent population.Patients:200 patients who presented to eligibility workers seeking financial assistance.Interventions:None.Measurements and Results:Sixty percent could not obtain care because they were illegal aliens, 40% could not obtain care because they did not meet the strict criteria of the assistance programs. Sixty percent of patients had a moderate to high likelihood of long-term disability from their illnesses; 38% of a subgroup were not able to find care four weeks after entering the study, and these patients appeared to have more severe disease than those who were able to find care.Conclusions:Many medically indigent persons with significant illnesses face serious financial barriers to access to medical care.

Routine admission laboratory testing for general medical patients.

We evaluated the usefulness of commonly ordered routine admission laboratory tests in 301 patients admitted consecutively to the internal medicine wards of a university teaching hospital. Using a consensus analysis approach, three Department of Medicine faculty members reviewed the charts of admitted patients to determine the impact of the test results on patient care. The evaluated tests were the urinalysis, hematocrit, white blood cell count, platelet count, six-factor automated multiple analysis (serum sodium, potassium, chloride, bicarbonate, glucose, and blood urea nitrogen), prothrombin time, partial thromboplastin time, chest x-ray, and electrocardiogram. Forty-five percent of the 3,684 tests were ordered for patients without recognizable medical indications. Twelve percent of these routine tests were abnormal, 5% led to additional laboratory testing, but only 0.5% led to change in the treatment of patients. We conclude that the impact of routine admission laboratory testing on patient care is very small and that there is little justification for ordering tests solely because of hospital admission.

The primary care specialties working together: a model of success in an academic environment.

In todays environment of decreasing resources and increasing competition among clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, if possible, integration. Academic leaders at the University of California, Irvine (UCI), have developed a collaborative model in which faculty in family medicine, general internal medicine, and general pediatrics cooperate extensively in education, research, and patient care. Generalist faculty jointly administer and teach both a four-year “doctoring” curriculum for medical students and an array of integrated curricula for primary care residents, including a communication skills course. Several primary faculty jointly developed a collaborative unit for health policy and research, now an active locus for multidisciplinary research. Other faculty worked together to develop a primary care medical group that serves as a model for interdisciplinary practice at UCI. Recently, the university recruited an associate dean for primary care who leads the new UCI Primary Care Coalition, reflecting and promoting this interspecialty cooperation. This coalition does not represent a step toward a generic primary care specialty; UCIs generalist disciplines have preserved their individual identities and structures. Yet interdisciplinary collaboration has allowed primary care faculty to share educational resources, a research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources while maximizing collective negotiating abilities and mutual success.

Deciding against corporate management of a state-supported academic medical center.

THE involvement of for-profit corporations in academic medical centers has stimulated wide debate. Critics have pointed out a series of potential problems with the corporate management of such cent...

Usefulness of routine admission complete blood cell counts on a general medical service

The usefulness of three components of the routine admission complete blood cell count (leukocyte count, hematocrit, and platelet count) was evaluated in 301 patients consecutively admitted to the internal medicine wards of a university teaching hospital. Using a consensus analysis approach, three faculty members reviewed the patients’ charts to determine which tests were performed routinely, which tests were abnormal, and which routine tests led to diagnostic or therapeutic changes. Overall, 55.3% of the tests were considered routine admission tests. Abnormalities were detected in 13.6% of the routine leukocyte counts, in 8.2% of the routine hematocrit levels, and in 12.4% of the routine platelet counts. However, treatment was changed for only three patients, all of whom had low hematocrits; this amounted to 0.6% of all tests. Furthermore, only one of the three patients received appropriate treatment that might have been withheld if a routine hematocrit determination had not been ordered. The authors conclude that the impact of routine admission complete blood cell counts on patient management is small and that the practice of ordering this test for all hospitalized patients could be eliminated with little adverse effect on patient care.