Marcy E. Rosenbaum

Answering physicians' clinical questions: obstacles and potential solutions.

OBJECTIVE To identify the most frequent obstacles preventing physicians from answering their patient-care questions and the most requested improvements to clinical information resources. DESIGN Qualitative analysis of questions asked by 48 randomly selected generalist physicians during ambulatory care. MEASUREMENTS Frequency of reported obstacles to answering patient-care questions and recommendations from physicians for improving clinical information resources. RESULTS The physicians asked 1,062 questions but pursued answers to only 585 (55%). The most commonly reported obstacle to the pursuit of an answer was the physicians doubt that an answer existed (52 questions, 11%). Among pursued questions, the most common obstacle was the failure of the selected resource to provide an answer (153 questions, 26%). During audiotaped interviews, physicians made 80 recommendations for improving clinical information resources. For example, they requested comprehensive resources that answer questions likely to occur in practice with emphasis on treatment and bottom-line advice. They asked for help in locating information quickly by using lists, tables, bolded subheadings, and algorithms and by avoiding lengthy, uninterrupted prose. CONCLUSION Physicians do not seek answers to many of their questions, often suspecting a lack of usable information. When they do seek answers, they often cannot find the information they need. Clinical resource developers could use the recommendations made by practicing physicians to provide resources that are more useful for answering clinical questions.

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.

Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study

Background: Less than half of eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to describe physicians’ reasons for screening or not screening specific patients for CRC and their approach to CRC testing discussions. Methods: This study used mixed-methods. Physicians described their reasons for screening or not screening 6 randomly chosen patients who were eligible for CRC screening (3 screened and 3 not screened) whose CRC testing status was ascertained by medical record review. Verbatim transcripts from physicians responding to structured interview questions were used to identify themes. Specific elements of discussion were examined for their association with each physicians screening rate. Fifteen randomly chosen Iowa family physicians from the Iowa Research Network stratified by privileges to perform colonoscopy, flexible sigmoidoscopy, or neither procedure dictated the reasons why 43 patients were screened and 40 patients were not screened. Results: Reasons patients were not up to date fell into 2 major categories: (1) no discussion by physician (50%) and (2) patient refusal (43%). Reasons for no discussion included lack of opportunity, assessment that cost would be prohibitive, distraction by other life issues/health problems, physician forgetfulness, and expected patient refusal. Patients declined because of cost, lack of interest, autonomy, other life issues, fear of screening, and lack of symptoms. Patients who were up to date received (1) diagnostic testing (for previous colon pathology or symptoms; 56%) or (2) asymptomatic screening (44%). Physicians who were more adamant about screening had higher screening rates (P < .05; Wilcoxon rank sum). Physicians framed their recommendations differently (“I recommend” vs “They recommend”), with lower screening rates among physicians who used “they recommend” (P = .05; Wilcoxon rank sum). Conclusions: Reasons many patients remain unscreened for CRC include (1) factors related to the health care system, patient, and physician that impede or prevent discussion; (2) patient refusal; and (3) the focus on diagnostic testing. Strategies to improve screening might include patient and physician education about the rationale for screening, universal coverage for health maintenance exams, and development of effective tracking and reminder systems. The words physicians choose to frame their recommendations are important and should be explored further.

A European consensus on learning objectives for a core communication curriculum in health care professions

OBJECTIVE To develop learning objectives for a core communication curriculum for all health care professions and to survey the acceptability and suitability of the curriculum for undergraduate European health care education. METHODS Learning objectives for a Health Professions Core Communication Curriculum (HPCCC) in undergraduate education were developed based on international literature and expert knowledge by an international group of communication experts representing different health care professions. A Delphi process technique was used to gather feedback and to provide a consensus from various health care disciplines within Europe. RESULTS 121 communication experts from 15 professional fields and 16 European countries participated in the consensus process. The overall acceptance of the core communication curriculum was high. 61 core communication objectives were rated on a five-point scale and found to be relevant for undergraduate education in health care professions. A thematic analysis revealed the benefits of the HPCCC. CONCLUSIONS AND PRACTICE IMPLICATIONS Based on a broad European expert consensus, the Health Professions Core Communication Curriculum can be used as a guide for teaching communication inter- and multi-professionally in undergraduate education in health care. It can serve for curriculum development and support the goals of the Bologna process.

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.

Bridging the gap: How is integrating communication skills with medical content throughout the curriculum valued by students

OBJECTIVE To describe a program with integrated learning of communication and consultation skills developed with the intention of preventing deterioration of communication skills, and to present student evaluation data. METHODS Description and evaluation of the program through: (1) monthly student evaluations; (2) questionnaire on student perceptions about the integrated curriculum; (3) a questionnaire about the value of one specific integrated training preceding the pediatric clerkship. RESULTS Key components of training throughout years 3-6 are reinforcement throughout the clinical years, adapting communication training to the clinical context of clerkships using a sandwich model with cycles of preparation, clerkship, and reflection. EVALUATION response rates were 69%, 93% and 93%, respectively. Students value practicing integration of communication and medical content with SPs who represent the population of their next clerkships. They appreciate the multisource feedback during the training, feedback by clerkship specific specialists and SPs is valued most. CONCLUSIONS This description shows an example of an integrated curriculum that helps students to feel well prepared for their communication tasks in subsequent clerkships. PRACTICE IMPLICATIONS Designing and implementing communication curricula to address the issue of integration is feasible. The effects of such integrated programs should be subject to future studies.

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.

YouTube is the Most Frequently Used Educational Video Source for Surgical Preparation.

OBJECTIVE The purpose of this study was to evaluate surgical preparation methods of medical students, residents, and faculty with special attention to video usage. DESIGN Following Institutional Review Board approval, anonymous surveys were distributed to participants. Information collected included demographics and surgical preparation methods, focusing on video usage. Participants were questioned regarding frequency and helpfulness of videos, video sources used, and preferred methods between videos, reading, and peer consultation. Statistical analysis was performed using SAS. SETTING Surveys were distributed to participants in the Department of Surgery at the University of Iowa Hospitals and Clinics, a tertiary care center in Iowa City, Iowa. PARTICIPANTS Survey participants included fourth-year medical students pursuing general surgery, general surgery residents, and faculty surgeons in the Department of Surgery. A total of 86 surveys were distributed, and 78 surveys were completed. This included 42 learners (33 residents, 9 fourth-year medical students) and 36 faculty. RESULTS The overall response rate was 91%; 90% of respondents reported using videos for surgical preparation (learners = 95%, faculty = 83%, p = NS). Regarding surgical preparation methods overall, most learners and faculty selected reading (90% versus 78%, p = NS), and fewer respondents reported preferring videos (64% versus 44%, p = NS). Faculty more often use peer consultation (31% versus 50%, p < 0.02). Among respondents who use videos (N = 70), the most used source was YouTube (86%). Learners and faculty use different video sources. Learners use YouTube and Surgical Council on Resident Education (SCORE) Portal more than faculty (YouTube: 95% versus 73%, p < 0.02; SCORE: 25% versus 7%, p < 0.05). Faculty more often use society web pages and commercial videos (society: 67% versus 38%, p < 0.03; commercial: 27% versus 5%, p < 0.02). CONCLUSIONS Most respondents reported using videos to prepare for surgery. YouTube was the preferred source. Posting surgical videos to YouTube may allow for maximal access to learners who are preparing for surgical cases.

Through students' eyes: ethical and professional issues identified by third-year medical students during clerkships

Backround Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. Method We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. Results A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). Conclusions Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying “ethical” issues, “professional” issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives.

A Medical Interviewing Curriculum Intervention for Medical Students’ Assessment of Suicide Risk

ObjectiveEffective communication strategies are required to assess suicide risk. The authors determined whether a 2-hour simulated-patient activity during a psychiatry clerkship improved self-assessment of medical interviewing skills relevant to suicide risk-assessment.MethodsIn the 2-hour simulated-patient intervention, at least one psychiatrist, a non-clinician communication expert, and a specifically-trained simulated patient worked with groups of 4–6 students to address student-identified challenges with patient encounters involving suicide risk-assessment. Six of twelve clerkships between July 2010 and October 2011 were assigned to this educational intervention in addition to a communications curriculum.ResultsOn a retrospective pre—post self-assessment, the 61 of 118 students assigned to the intervention group reported greater improvements in relevant skills. The process of discovering/responding to patients’ feelings and identifying/addressing verbal and nonverbal cues specifically improved.ConclusionThe psychiatry clerkship provides a unique opportunity to reinforce and develop communications skills with a formal, skills-based curriculum.