Lynne Robins

Current trends in interprofessional education of health sciences students: A literature review

There is a pressing need to redesign health professions education and integrate an interprofessional and systems approach into training. At the core of interprofessional education (IPE) are creating training synergies across healthcare professions and equipping learners with the collaborative skills required for todays complex healthcare environment. Educators are increasingly experimenting with new IPE models, but best practices for translating IPE into interprofessional practice and team-based care are not well defined. Our study explores current IPE models to identify emerging trends in strategies reported in published studies. We report key characteristics of 83 studies that report IPE activities between 2005 and 2010, including those utilizing qualitative, quantitative and mixed method research approaches. We found a wide array of IPE models and educational components. Although most studies reported outcomes in student learning about professional roles, team communication and general satisfaction with IPE activities, our review identified inconsistencies and shortcomings in how IPE activities are conceptualized, implemented, assessed and reported. Clearer specifications of minimal reporting requirements are useful for developing and testing IPE models that can inform and facilitate successful translation of IPE best practices into academic and clinical practice arenas.

Educational Fellowship Programs: Common Themes and Overarching Issues

The trend toward intensive faculty development programs has been driven by a variety of factors, including institutional needs for educational expertise and leadership, as well as individual faculty members’ motivation to augment their educational expertise, teaching skills, and leadership skills. The nine programs described in this issue possess several common features that can be ascribed to shared perceptions of pervasive needs coupled with feasible educational resources and strategies to meet these needs. All programs identify a clear set of goals and objectives for their respective curricula. Curriculum domains include not only teaching skills but also educational research, curriculum development, and educational leadership. In spite of many similarities, each program reflects the unique character of its home institution, the faculty, educational resources, and the specific goals of the program. Each program has documented gains in such key outcomes as participant promotions, new leadership positions both locally and nationally, and scholarly productivity in the form of peer-reviewed papers and presentations. Evidence of institutional benefits includes the production of innovative curricula and a pool of educational leaders. The programs have also developed a community of knowledgeable scholars who interact with each other and serve as a catalyst for continuing change and educational improvement. Although each program was developed largely independently of the others, the common elements in their design provide opportunities to evaluate collaboratively the successful aspects of such programs and to share ideas and resources for program curricula between existing programs and with institutions considering implementing new programs.

Impact of a Pre-Clinical Clinical Skills Curriculum on Student Performance in Third-Year Clerkships

ABSTRACTBACKGROUNDResearch on the outcomes of pre-clinical curricula for clinical skills development is needed to assess their influence on medical student performance in clerkships.OBJECTIVETo better understand the impact of a clinical-skills curriculum in the pre-clinical setting on student performance.DESIGNWe conducted a non-randomized, retrospective, pre-post review of student performance evaluations from 3rd-year clerkships, before and after implementation of a clinical-skills curriculum, the Colleges (2001–2007).MAIN RESULTSComparisons of clerkship performance data revealed statistically significant differences favoring the post-Colleges group in the Internal Medicine clerkship for 9 of 12 clinical-skills domains, including Technical Communication Skills (p < 0.023, effect size 0.16), Procedural Skills (p < 0.031, effect size 0.17), Communication Skills (p < 0.003, effect size 0.21), Patient Relationships (p < 0.003, effect size 0.21), Professional Relationships (p < 0.021, effect size 0.17), Educational Attitudes (p < 0.001, effect size 0.24), Initiative and Interest (p < 0.032, effect size 0.15), Attendance and Participation (p < 0.007, effect size 0.19), and Dependability (p < 0.008, effect size 0.19). Statistically significant differences were identified favoring the post-Colleges group in technical communication skills for three of six basic clerkships (Internal Medicine, Surgery, and Pediatrics).CONCLUSIONSImplementation of a pre-clinical fundamental skills curriculum appears to be associated with improved clerkship performance in the 3rd year of medical school, particularly in the Internal Medicine clerkship. Similar curricula, focused on teaching clinical skills in small groups at the bedside with personalized mentoring from faculty members, may improve student performance. Continued efforts are needed to understand how to best prepare students for clinical clerkships and how to evaluate outcomes of similar pre-clinical skills programs.

Effectiveness of Intensive Physician Training in Upfront Agenda Setting

BackgroundPatients want all their concerns heard, but physicians fear losing control of time and interrupt patients before all concerns are raised.ObjectiveWe hypothesized that when physicians were trained to use collaborative upfront agenda setting, visits would be no longer, more concerns would be identified, fewer concerns would surface late in the visit, and patients would report greater satisfaction and improved functional status.Design and ParticipantsPost-only randomized controlled trial using qualitative and quantitative methods. Six months after training (March 2004—March 2005) physician-patient encounters in two large primary care organizations were audio taped and patients (1460) and physicians (48) were surveyed.InterventionExperimental physicians received training in upfront agenda setting through the Establishing Focus Protocol, including two hours of training and two hours of coaching per week for four consecutive weeks.Main MeasuresOutcomes included agenda setting behaviors demonstrated during the early, middle, and late encounter phases, visit length, number of raised concerns, patient and physician satisfaction, trust and functional status.Key ResultsExperimental physicians were more likely to make additional elicitations (p < 0.01) and their patients were more likely to indicate agenda completion in the early phase of the encounter (p < 0.01). Experimental group patients and physicians raised fewer concerns in the late encounter phase (p < 0.01). There were no significant differences in visit length, total concerns addressed, patient or provider satisfaction, or patient trust and functional statusConclusionCollaborative upfront agenda setting did not increase visit length or the number of problems addressed per visit but may reduce the likelihood of “oh by the way” concerns surfacing late in the encounter. However, upfront agenda setting is not sufficient to enhance patient satisfaction, trust or functional status. Training focused on physicians instead of teams and without regular reinforcement may have limited impact in changing visit content and time use.

Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis

Objective To characterise suicide-risk discussions in depressed primary-care patients. Design Secondary analysis of recordings and self reports by physicians and patients. Descriptive statistics of depression and suicide-related discussion, with qualitative extraction of disclosure, enquiry and physician response. Setting 12 primary-care clinics between July 2003 and March 2005. Participants 48 primary-care physicians and 1776 adult patients. Measures Presence of depression or suicide-related discussions during the encounter; patient and physician demographics; depression symptom severity and suicide ideation as measured by the Patient Health Questionnaire (PHQ9); physicians decision-making style as measured by the Medical Outcomes Study Participatory Decision-Making Scale; support for autonomy as measured by the Health Care Climate Questionnaire; trust in their physician as measured by the Primary Care Assessment Survey; physician response to suicide-related enquiry or disclosure. Results Of the 1776 encounters, 128 involved patients scoring >14 on the PHQ9. These patients were seen by 43 of the 48 physicians. Suicide ideation was endorsed by 59% (n=75). Depression was discussed in 52% of the encounters (n=66). Suicide-related discussion occurred in only 11% (n=13) of encounters. 92% (n=12) of the suicide discussions occurred with patients scoring <2 on PHQ9 item 9. Suicide was discussed in only one encounter with a male. Variation in elicitation and response styles demonstrated preferred and discouraged interviewing strategies. Conclusions Suicide ideation is present in a significant proportion of depressed primary care patients but rarely discussed. Men, who carry the highest risk for suicide, are unlikely to disclose their ideation or be asked about it. Patient-centred communication and positive healthcare climate do not appear to increase the likelihood of suicide related discussion. Physicians should be encouraged to ask about suicide ideation in their depressed patients and, when disclosure occurs, facilitate discussion and develop targeted treatment plans.

Physical activity training for functional mobility in older persons.

The effectiveness of low-intensity physical activity for improving functional ability and psycho logical well-being in chronically impaired older individuals was demonstrated in a pilot study. Participants who completed 6 weeks of structured low-intensity exercise (N = 77) improved in the time and number of steps required to walk a measured course, in self-assessments of mobility and flexibility, and in three measures of well-being. Those who continued to exercise in a peer-led program (n = 32) maintained improvements in mobility and optimism after 18 weeks.

Resident perceptions of the educational value of night float rotations.

Background: Night float rotations are being increasingly used in the era of resident physician work-hour regulations, but their impact on resident education is not clear. Purpose: Our objective was to clarify resident perceptions of the educational aspects of night float rotations. Methods: An anonymous survey of internal medicine residents at a university-based residency program was completed. Results: Responses were received from 116 of 163 surveyed residents (71%). Residents attended less residents’ report (0.10 ± .43 vs. 2.70 + 0.93 sessions/week, p< .001) and fewer grand rounds sessions (0.14 ± 0.25 vs. 0.43 ± 0.28 sessions/week, p< .001) and spent less time reading, (2.63 ± 2.0 vs. 3.33 ± 1.6 hr/week, p< .001) interacting with attending physicians (0.57 ± 1.1 vs. 2.97 ± 1.5 hr/week, p< .001) and sleeping at home (6.3 ± 1.2 vs. 7.10 ± 0.9 hr/day, p< .001) on night float rotations than on non–night float rotations. Residents had strongly negative opinions about the educational value of night float, sleep cycle adjustment issues, and impact on their personal lives, which correlated with resident evaluations from the regular program evaluation process. In free responses, residents commented that they liked the autonomy and opportunity to improve triage skills on these rotations and confirmed their negative opinions about the sleep–wake cycle and interference with personal lives. Conclusions: Internal medicine residents at a university-based program have negative opinions regarding the educational value of night float rotations. Further work is necessary to determine whether problems exist across programs and specialties.

The difficulty of sustaining curricular reforms: a study of "drift" at one school.

In 1997, five years after a major curricular reform at the University of Michigan Medical School, the authors revisited the Goals for Medical Education (written by faculty to guide the reform process) to identify factors that had facilitated or hindered their achievement. By reviewing responses to identical questionnaires circulated to faculty in 1993 and again in 1997, they learned that considerably more lectures were being used to deliver curricular content in the first-year curriculum than the faculty thought was ideal, and that less social science, humanities, and ethics material was being presented in the first year than the faculty thought was ideal. The authors also learned that consensus between faculty basic scientists and faculty clinicians about the content that would make up an ideal first-year curriculum had diverged since adoption of the new curriculum. Movement toward decreasing the amounts of social sciences, humanities, and ethics in the first year of medical school was particularly pronounced among the basic scientists, who felt this material was being taught prematurely and at the expense of essential basic science content. In contrast, by 1997 much closer agreement had developed between the two groups regarding time they would allocate for lectures; this agreement unfortunately reflected a stagnation in the adoption of active learning methods. Movement toward increasing the amount of time for lectures in the first-year curriculum was particularly pronounced among the clinicians, who reported feeling more and more pressured to bring in clinical revenues. Based on faculty comments and the schools experience with centralized governance and centralized funding, the authors propose a direct linkage between institutional funding to departments and the teaching effort of faculty in the departments, and sufficient, centralized funding to relieve pressure on faculty and to foster educational creativity. They maintain that this may be the most effective way to guarantee ongoing innovation, support interdisciplinary teaching, and subsequently move the curriculum and teachers completely away from content that is isolated within traditional department structures. At the same time they acknowledge that changing faculty attitudes presents a challenge.

Barriers and Facilitators to Evidence-based Blood Pressure Control in Community Practice

Introduction: The Electronic Communications and Home Blood Pressure Monitoring trial (e-BP) demonstrated that team care incorporating a pharmacist to manage hypertension using secure E-mail with patients resulted in almost twice the rate of blood pressure (BP) control compared with usual care. To translate e-BP into community practices, we sought to identify contextual barriers and facilitators to implementation. Methods: Interviews were conducted with medical providers, staff, pharmacists, and patients associated with community-based primary care clinics whose physician leaders had expressed interest in implementing e-BP. Transcripts were analyzed using qualitative template analysis, incorporating codes derived from the Consolidated Framework for Implementation Research (CFIR). Results: Barriers included incorporating an unfamiliar pharmacist into the health care team, lack of information technology resources, and provider resistance to using a single BP management protocol. Facilitators included the interventions perceived potential to improve quality of care, empower patients, and save staff time. Sustainability of the intervention emerged as an overarching theme. Conclusion: A qualitative approach to planning for translation is recommended to gain an understanding of contexts and to collaborate to adapt interventions through iterative, bidirectional information gathering. Interviewees affirmed that web pharmacist care offers small primary care practices a means to expand their workforce and provide patient-centered care. Reproducing e-BP in these practices will be challenging, but our interviewees expressed eagerness to try and were optimistic that a tailored intervention could succeed.

Piloting team simulations to assess interprofessional skills

Medical Education and Biomedical Informatics, Department of Medical Education and Biomedical Informatics, University of Washington School of Medicine, Department of Rehabilitation Medicine, University of Washington, University of Washington School of Social Work, Department of Pharmacy, University of Washington School of Pharmacy, University of Washington School of Dentistry, and Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Washington, USA