Mark D. Holden

OVER-THE-COUNTER MEDICATIONS : DO YOU KNOW WHAT YOUR PATIENTS ARE TAKING ?

The pharmacopeia of over-the-counter (OTC) drugs is ever expanding, and many of these nonprescription agents cause a variety of adverse drug-drug and drug-patient interactions. It is therefore essential that physicians be aware of the more than 700 active ingredients available in OTC drugs at the local store and make a concerted effort to identify which ones their patients are taking. Healthcare providers also need to educate patients about the potential effects of OTC drugs and encourage them to consult either their physician or their pharmacist before attempting self-medication.

Professional Identity Formation in Medical Education: The Convergence of Multiple Domains

There has been increasing emphasis on professionalism in medical education over the past several decades, initially focusing on bioethical principles, communication skills, and behaviors of medical students and practitioners. Authors have begun to discuss professional identity formation (PIF), distinguishing it as the foundational process one experiences during the transformation from lay person to physician. This integrative developmental process involves the establishment of core values, moral principles, and self-awareness. The literature has approached PIF from various paradigms—professionalism, psychological ego development, social interactions, and various learning theories. Similarities have been identified between the formation process of clergy and that of physicians. PIF reflects a very complex process, or series of processes, best understood by applying aspects of overlapping domains: professionalism, psychosocial identity development, and formation. In this study, the authors review essential elements of these three domains, identify features relevant to medical PIF, and describe strategies reported in the medical education literature that may influence PIF.

Professional identity formation: creating a longitudinal framework through TIME (Transformation in Medical Education).

The University of Texas System established the Transformation in Medical Education (TIME) initiative to reconfigure and shorten medical education from college matriculation through medical school graduation. One of the key changes proposed as part of the TIME initiative was to begin emphasizing professional identity formation (PIF) at the premedical level. The TIME Steering Committee appointed an interdisciplinary task force to explore the fundamentals of PIF and to formulate strategies that would help students develop their professional identity as they transform into physicians. In this article, the authors describe the task force’s process for defining PIF and developing a framework, which includes 10 key aspects, 6 domains, and 30 subdomains to characterize the complexity of physician identity. The task force mapped this framework onto three developmental phases of medical education typified by the undergraduate student, the clerkship-level medical student, and the graduating medical student. The task force provided strategies for the promotion and assessment of PIF for each subdomain at each of the three phases, in addition to references and resources. Assessments were suggested for student feedback, curriculum evaluation, and theoretical development. The authors emphasize the importance of longitudinal, formative assessment using a combination of existing assessment methods. Though not unique to the medical profession, PIF is critical to the practice of exemplary medicine and the well-being of patients and physicians.

Do students do what they write and write what they do? The match between the patient encounter and patient note

Background Patient notes are used for a variety of purposes in health care. Medical students are taught the structure of patient notes early in training. Review of patient notes are then used to assess synthesis and integration of patient information. It is critical that the information in the note accurately and completely represents the student-patient encounter. Method The authors reviewed videotapes of students in three standardized-patient based scenarios and compared what occurred during the physical examination with the subsequent documentation in the patient note. Results In all, 207 encounter-note pairs were reviewed. Only 8 (4%) of the notes completely and accurately represented what occurred during the encounter. Problems with underdocumentation, overdocumentation, and inaccurate documentation of physical findings were seen for all three patient scenarios. Conclusions These findings highlight the need to teach and assess both data gathering skills and written documentation of findings in medical training.

Incorporating simulators in a standardized patient exam.

OBJECTIVE Using simulated patients during a clinical skills exam that involves many students has the advantage of standardizing the delivery of historical data. One major disadvantage is the inability to standardize the physical exam findings. We designed a simulated patient exam that incorporates simulated abnormal physical exam findings. DESCRIPTION The simulated patient exam case was divided into three separate stations: (1) the simulated patients history, (2) the simulated physical exam, and (3) the presentation station. Dyspnea was chosen as the chief complaint because of the broad differential of possible cardiac and pulmonary auscultatory findings. In the first station, students obtained historical data from the standardized simulated patient. Students were graded on their ability to ask appropriate historical questions. Trained observers were used to verify the numbers of historical cues obtained by the students. The second station consisted of simulated physical exam findings. Students first measured the blood pressure on a commercially available blood pressure simulator arm from the Medical Plastics Laboratory, Inc., Gatesville, TX. Students then auscultated an abnormal digital heart sound and pulmonary sound from a small auscultation transducer developed by Andries Acoustics, Spicewood, TX. Students also palpated a simulated pulse from a newly developed pulse transducer. Digital cardiopulmonary sounds and pulse data were recorded onto a CD-ROM disc and transmitted to the small transducers via a CD-ROM disc player. Students used their own stethoscopes to auscultate cardiopulmonary sounds from the small transducers. The students were graded in the second station on their ability to accurately measure a blood pressure, identify abnormal cardiopulmonary digital sounds, and finally describe a peripheral pulse. In the third station, students presented the historical data and physical exam findings to a faculty member, and then provided a differential diagnosis list based on their key findings from the other two stations. A total of 171 students (n = 171) completed the simulated patient exam. Each student completed the exam in 45 minutes. DISCUSSION In our simulated patient exam, students were evaluated not only on their data-gathering skills for key historical findings but also on the ability to correctly identify key physical exam findings such as abnormal cardiopulmonary sounds. Key physical exam findings were then integrated into the clinical decision-making process, which was presented in the faculty presentation station. Simulated patients with abnormal cardiopulmonary findings can be used for testing purposes. However, cardiac auscultatory abnormalities such as the ventricular S3 gallop are difficult to find and usually occur in a decompensated state such as heart failure. Other physical exam findings such as pulmonary crackles and wheezes also occur in decompensated conditions. Therefore, the use of simulators during a simulated patient exam offers the possibility of introducing several abnormal physical exam findings without having an unstable patient present in an exam setting. Further, the use of simulated physical exam findings allows for complete standardization of a clinical-simulated patient exam.

A comparison of faculty-led small group learning in combination with computer-based instruction versus computer-based instruction alone on identifying simulated pulmonary sounds.

Background: Computer-based learning has gained widespread acceptance in medical curricula, but can it replace faculty-led teaching. Purpose: To investigate the effectiveness of independent computer-based learning of pulmonary auscultation alone and in combination with faculty-led teaching. Methods: The first method involved independent computer-based instruction (CBI; Group 1) of 113 second-year medical students. The second method involved a combination of faculty-led instruction and independent CBI (Group 2) of 79 second-year medical students. A pretest-posttest method of assessment was used. Results: The pretest showed recognition rates of 48% for Group 1 and 46% for Group 2, whereas the posttest showed recognition rates of 81% for Group 1 and 88% for Group 2. The posttest clinical correlation scores were identical with both groups scoring 93 percent. Conclusions: The study demonstrates that student learning of pulmonary auscultation is similar whether a computer-based independent instructional approach is used alone or in combination with faculty-led sessions.

A Methodological Review of the Assessment of Humanism in Medical Students.

Background Humanism is a complex construct that defies simplistic measurement. How educators measure humanism shapes understanding and implications for learners. This systematic review sought to address the following questions: How do medical educators assess humanism in medical students, and how does the measurement impact the understanding of humanism in undergraduate medical education (UME)? Method Using the IECARES (integrity, excellence, compassion, altruism, respect, empathy, and service) Gold Foundation framework, a search of English literature databases from 2000 to 2013 on assessment of humanism in medical students revealed more than 900 articles, of which 155 met criteria for analysis. Using descriptive statistics, articles and assessments were analyzed for construct measured, study design, assessment method, instrument type, perspective/source of assessment, student level, validity evidence, and national context. Results Of 202 assessments reported in 155 articles, 162 (80%) used surveys; 164 (81%) used student self-reports. One hundred nine articles (70%) included only one humanism construct. Empathy was the most prevalent construct present in 96 (62%); 49 (51%) of those used a single instrument. One hundred fifteen (74%) used exclusively quantitative data; only 48 (31%) used a longitudinal design. Construct underrepresentation was identified as a threat to validity in half of the assessments. Articles included 34 countries; 87 (56%) were from North America. Conclusions Assessment of humanism in UME incorporates a limited scope of a complex construct, often relying on single quantitative measures from self-reported survey instruments. This highlights the need for multiple methods, perspectives, and longitudinal designs to strengthen the validity of humanism assessments.

The impact of the location and structure of an ambulatory rotation on cognitive knowledge and performance.

With the increasing shift to community-based ambulatory education, it is essential to gain a better understanding of the impact of these changes. To assess the impact of the location and structure of an ambulatory internal medicine clerkship rotation on cognitive knowledge and clinical performance, students were assigned to one of the following: (a) a multi-disciplinary ambulatory clerkship (MAC), (b) the office of a community-based general internist, or (c) a university-based internal medicine ambulatory clinic. The groups were compared on the internal medicine clerkship examination and preceptor ratings controlling for introduction to clinical medicine course performance via analysis of covariance. MAC students were rated lower than the other two groups by their preceptors. There were no other statistically significant differences. The structure and location of the rotation had little impact on cognitive knowledge. The impact of the structure of the rotation on clinical performance is less clear suggesting that further research is needed.

Developing a presentation and problem-solving station in a multistation standardized-patient examination.

No abstract available.