Michael C. Hosokawa

Problem-based learning outcomes: ten years of experience at the University of Missouri-Columbia School of Medicine.

Purpose To add to a previous publication from the University of Missouri—Columbia School of Medicine (UMCSOM) on students’ improvement in United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores after the implementation of a problem-based learning (PBL) curriculum by studying the performance of ten PBL class cohorts at the UMCSOM. Method Characteristics of graduating classes matriculating in both traditional and PBL curricula, 1993–2006, were compared for Medical College Admission Test component scores, undergraduate grade point averages, performance on the USMLE Step 1 and Step 2 exams, faculty contact hours, and residency directors’ evaluations of UMCSOM graduates’ performance in the first year of residency. Results Mean scores of six of the ten comparisons for USMLE Step 1 and six of nine comparisons for USMLE Step 2 are significantly higher (p < .01) for UMCSOM PBL students than for first-time examinees nationally. These differences cannot be accounted for by preselection of academically advantaged students, increased time on task, or reduced class size. Gains in performance continue into residency, as evidenced by program directors’ perceptions of superior performance of UMCSOM PBL graduates. Conclusions The PBL curricular changes implemented with the graduating class of 1997 resulted in higher performances on USMLEs and improved evaluations from residency program directors. These changes better prepare graduates with knowledge and skills needed to practice within a complex health care system. Outcomes reported here support the investment of financial and human resources in our PBL curriculum.

Collaborative practice and provider styles of delivering health care

The delivery of primary health care involves complex interactive communication between the provider and patient. Describing the manner or style of this communication is important to more completely understand the delivery of primary health care. The purpose of this study was to examine providers style of interaction with the patient and to compare the styles of nurse practitioners and physicians in joint practice. A total of 412 provider/patient clinic visits including 276 with physicians and 136 with nurse practitioners were videotaped and analyzed using a content-based interactive analysis system. Five provider style dimension indices were constructed including affiliation, control, somatic, psychosocial, and information indices. The results of this study show that the development of a content-based interactional analysis system which focuses on clinician activities can be useful in describing important aspects of the provider/patient encounter. Overall, there was little difference between nurse practitioner and physician style of interaction. Nurse practitioners, however, exhibited significantly more concern with psychosocial issues than physicians. Type of visit and visit history were also factors associated with provider style. Using the style dimension indices constructed for this study a typology of provider styles was developed.

Influencing Residency Choice and Practice Location Through a Longitudinal Rural Pipeline Program

Purpose The University of Missouri School of Medicine developed the Rural Track Pipeline Program (MU-RTPP) to increase the supply and retention of rural physicians statewide. The MU-RTPP features a preadmissions program for rural students (Rural Scholars), a Summer Community Program for rising second-year students, a six-month Rural Track Clerkship (RTC) Program for third-year students, and a Rural Track Elective Program for fourth-year students. The purpose of this study is to report the specialty choices and first practice locations of Rural Scholars, RTC-only participants, and Rural Track Clerkship Plus (RTC+) participants (students who participated in the RTC Program plus an additional MU-RTPP component). Method The authors compared the residency specialty choices of 48 Rural Scholars (tracked since 2002) with those of 506 nonparticipants and the residency specialty choices of 83 RTC participants and 75 RTC+ participants (tracked since 1997) with those of 840 nonparticipants. The authors calculated the relative risk (RR) for the likelihood of participants matching into primary care compared with nonparticipants and analyzed first practice location. Results Rural Scholars were more than twice as likely to match into family medicine (RR = 2.6; 95% confidence interval 1.5–4.4). RTC and RTC+ participants entered primary care, especially family medicine, at rates significantly higher than nonparticipants. Over 57% of students who participated in the RTC program (and potentially other MU-RTPP offerings) chose a rural location for their first practice. Conclusions The longitudinal MU-RTPP successfully recruits students for rural and primary care practice to address the health care needs of Missouri.

What criteria do faculty use when rating students as potential house officers

Third-year medical students’ grades are a combination of faculty observations, National Board of Medical Examiners examinations, and other departmental specific course requirements. Faculty evaluations include assessment of students’ clinical skills, and a global rating for potential as house officer. We wished to better understand the ‘potential as house officer’ and to understand if these competencies were shared across the third year or unique to a given discipline. We then examined the relationship between house officer potential and performance on traditional measures of success. We analyzed the narrative comments from faculty evaluations of third-year students who faculty rated as ‘Outstanding’ in the house officer potential category. The low correlations found between house officer potential and traditional measures of academic success indicate that items beyond the stated learning objectives are influencing faculty evaluation of clinical students. Our data suggest that the awarding of ‘potential for house officer’ reflects the students ability to work as part of a health care team. Although there appear to be common elements among the house officer comments, we also observed discipline specific differences. Given the importance placed on house officer potential, more conversation is needed to develop a common language across the third-year courses.

Factors Contributing to the Specialty Selection, Practice Location, and Retention of Physicians in Rural Practice

This qualitative study describes the phenomenon of becoming a rural physician and the experiences that influence physicians to choose and stay in rural practice. Fifteen individual interviews were conducted. For the participants in this study, rural upbringing, family values, early experiences regarding medicine, and identity in place were experiences prior to medical school that influenced the desire to practice and live in a rural area. Rural clinical experiences during medical school and residency, the culture of the medical school, and preceptor relationships were factors that influenced physicians’ choices. Family, partners, and loan forgiveness were factors that influenced practice type and location. Professional support and integration into the community were factors influencing retention. This information is valuable to medical educators, administrators, and community leaders interested in addressing the maldistribution of physicians and, ultimately, health disparities affecting rural citizens.

Evaluation of a self-teaching program

A self-teaching booklet on hypertension was evaluated in two populations: clients attending public health screening clinics and inpatients at a Veterans Administration hospital. Participants were randomized into an education or a control group. Evaluation consisted of measuring knowledge gained from the booklet immediately after reading it and retention of key concepts two weeks later. Men did better than women, and VA education participants did better than VA controls. No differences were detected between the public health education and control groups or the combined VA and public health) education and control groups. The self-teaching booklet alone did not appear to yield a measurable amount of new knowledge. Health professionals, when educating patients and evaluating programs, should consider combinations of educational methods when using self-teaching programs.

Take a Deep Breath: A Pilot Study Demonstrating a Significant Reduction in Blood Pressure with 15 Minute Daily Pranayama Breathing

Approximately one third of US patients are diagnosed with pre-hypertension, associated with significant health risks. Current treatment guidelines recommend lifestyle modification as first-line therapy for pre-hypertension, and a few recent studies have indicated the potential for mind-body therapies to reduce blood pressure in pre-hypertensive patients. Our study investigated the effect of daily practice of Pranayama, a group of yogic breathing exercises, on blood pressure of eight pre-hypertensive individuals. Participants received weekly Pranayama instruction and blood pressure measurements were obtained. Daily Pranayama practice resulted in statistically significant blood pressure reduction of 11 points (systolic) and 8 points (diastolic) between baseline and week six. Blood pressure measurements at week nine were similar to week six. The ease with which the technique of Pranayama can be learned and practiced by patients and its potential to significantly lower blood pressure makes this technique a promising non-pharmacologic tool for blood pressure reduction in pre-hypertensive patients.

Osteopathic physician location and specialty choice

Physician distribution continues as a major national issue despite the projected oversupply of physicians by 1990. Kirksville College of Osteopathic Medicine (KCOM) in Kirksville, Missouri, has a high percentage of its graduates going into rural primary care. In this study of physicians who graduated from KCOM from 1930 to 1974, the authors sought to identify the factors influencing physicians to select rural primary care. The size of the physicians hometown, KCOM curricular experiences, and faculty role models were the most important factors influencing a physician to select rural primary care. While these findings are similar to other studies, this is the first to examine osteopathic medicine.

Can Today’s Medical School Faculty Teach Tomorrow’s Physicians about Patient-Centered Care?

The concepts of patient-centered care and the medical home should bring changes in the way we educate future health professionals. The contributions of the behavioral faculty and the behavioral sciences in medical education are critical to these changes as curricula are re-designed and experiential learning replaces theory-based courses. The challenge for today’s faculty is how to teach future health professionals for practice in a health care structure that does not yet exist.

UNIVERSITY OF MISSOURI’S “REINCARNATED” WORKSHOP FOR NEW CHAIRS OF DEPARTMENTS OF FAMILY MEDICINE

The Department of Family and Community Medicine at the University of Missouri (MU) hosted successful workshops in the 1990s for more than 25 family medicine department chairs and leaders in academic family medicine. In 2012 and again in 2013, we have conducted reincarnations of this workshop for 11 new chairs (7 in 2012 and 4 in 2013). This program was conceived by Michael Hosokawa, EdD and Jack Colwill, MD in the 1990s as a way to help train the second generation of family medicine department chairs. They turned their idea into a successfully funded proposal under the Faculty Development series of HRSA-funded Title VII programs. First Jack Colwill then Hal Williamson led the New Chairs Workshop involving senior leaders from the Department of Family and Community Medicine at MU. Also vital to the success of the program was the partnership with the Society of Teachers of Family Medicine as Roger Sherwood, STFM Executive Director served as a consultant to each of those early sessions. Also key to the workshop’s success was another senior family medicine chair who participated as a consultant. When this program was reborn in 2012, the Academic Departments of Family Medicine (ADFM) became the co-sponsor with MU Family and Community Medicine. Using a case-based approach, attendees bring to the workshop real world challenges they are facing. While attendees serve as the experts, MU faculty and a consultant from ADFM also facilitate. The faculty from MU include: Jack Colwill (former chair, former Interim Dean, and leader of past Chairs Workshops), Mike Hosokawa (former dean for curriculum and director of faculty development), Hal Williamson (former chair and president of ADFM, now Vice Chancellor for Health Affairs), Mike LeFevre (health system chief information medical officer, vice chair and clinical director), Steven Zweig (current MU department chair and Chair of ADFM Leadership Development Committee) and others.