Paul E. Ogden

What Can Medical Education Learn From the Neurobiology of Learning

The last several decades have seen a large increase in knowledge of the underlying biological mechanisms that serve learning and memory. The insights gleaned from neurobiological and cognitive neuroscientific experimentation in humans and in animal models have identified many of the processes at the molecular, cellular, and systems levels that occur during learning and the formation, storage, and recall of memories. Moreover, with the advent of noninvasive technologies to monitor patterns of neural activity during various forms of human cognition, the efficacy of different strategies for effective teaching can be compared. Considerable insight has also been developed as to how to most effectively engage these processes to facilitate learning, retention, recall, and effective use and application of the learned information. However, this knowledge has not systematically found its way into the medical education process. Thus, there are considerable opportunities for the integration of current knowledge about the biology of learning with educational strategies and curricular design. By teaching medical students in ways that use this knowledge, there is an opportunity to make medical education easier and more effective. The authors present 10 key aspects of learning that they believe can be incorporated into effective teaching paradigms in multiple ways. They also present recommendations for applying the current knowledge of the neurobiology of learning throughout the medical education continuum.

Using simulation to orient code blue teams to a new hospital facility.

Objectives: Prompt and successful cardiopulmonary resuscitation during a sudden cardiac arrest can be hindered by multiple variables, ie, ineffective communication, stress, lack of training, and an unfamiliar environment, such as a new hospital facility. The main objective of the study was to use high-fidelity simulations to orient Code Blue Teams (CBTs) to critical events in a new hospital facility. A secondary objective was to elucidate factors that may have contributed to responses by debriefing teams. Methods: Mock Code Blue exercises using high-fidelity simulation were implemented in real workplace settings to orient CBTs to critical events. We measured arrival time of first responder, crash cart to code site, first six CBT responders, first chest compression, and first electrical shock. After each mock code, participants were debriefed to assess any barriers to effective response and decision making. Results: Twelve mock codes were conducted at different locations of the new facility. Sixty-nine percent of the participants reported that the training was beneficial. The median time of arrival of the first responders was 42 seconds and the first CBT member was 66 seconds. The median time to initiation of chest compressions was 80 seconds, crash cart arrival was 68 seconds, and first electrical shock was 341 seconds. An additional outcome of the study was the identification of facility and systems issues that had the potential to impact patient safety. Conclusions: Clinical simulation can be effectively used to orient CBTs and identify critical safety issues in a newly constructed healthcare facility.

Medical Students' Perspectives on and Responses to Abuse During the Internal Medicine Clerkship

Background: The abuse of medical students on clinical rotations is a recognized problem, but the effects on students and their responses warrant further study. Purpose: To determine the severity of student abuse and the effects of abuse on students during the internal medicine clerkship. Methods: Internal medicine clerks at 11 medical schools (N = 1,072) completed an exit survey. Students were asked whether they had been abused. If they had, they were asked about the severity of the abuse, whether they reported it, and its effects on them. Results: Of the responding students, 123 (11%) believed they had been abused. Only 31% of the students who felt abused reported the episodes to someone. The most common consequences of the events included poor learning environments, lack of confidence, and feelings of depression, anger, and humiliation. Conclusion: Students described a variety of personal and educational effects of abuse. They generally did not report abuse because of fear of retaliation and the belief that reporting is pointless.

Do Attending Physicians, Nurses, Residents, and Medical Students Agree on What Constitutes Medical Student Abuse?

Background Whether attending physicians, residents, nurses, and medical students agree on what constitutes medical student abuse, its severity, or influencing factors is unknown. Method We surveyed 237 internal medicine attending physicians, residents, medical students, and nurses at 13 medical schools after viewing five vignettes depicting potentially abusive behaviors. Results The majority of each group felt the belittlement, ethnic insensitivity, and sexual harassment scenarios represented abuse but that excluding a student from participating in a procedure did not. Only a majority of attending physicians considered the negative feedback scenario as abuse. Medical students rated abuse severity significantly lower than other groups in the belittlement scenario (p < .05). Respondents who felt abused as students were more likely to rate behaviors as abusive (p < .05). Conclusions The groups generally agree on what constitutes abuse, but attending physicians and those abused as students may perceive more behaviors as abusive.

Oral versus written feedback in medical clinic

OBJECTIVE: To determine whether residents perceived oral, face-to-face feedback about their continuity clinic performance as better than a similar, written version.DESIGN: Single-blind, randomized controlled trial.SETTING: Two university-based, internal medicine residency clinics.PARTICIPANTS: All 68 internal medicine and combined program (medicine-pediatrics, medicine-psychiatry, medicine-neurology, and preliminary year) residents and their clinic preceptors.MEASUREMENTS AND MAIN RESULTS: Residents at each program were separately randomized to oral or written feedback sessions with their clinic preceptors. The oral and written sessions followed similar, structured formats. Both groups were later sent questionnaires about aspects of the clinic. Sixty-five (96%) of the residents completed the questionnaire. Eight of the 19 questions dealt with aspects of feedback. A feedback scale was developed from the survey responses to those eight questions (α=.86). There were no significant differences in the responses to individual questions or in scale means (p>.20) between the two feedback groups. When each university was analyzed separately, one had a higher scale mean (3.10 vs 3.57, p=.047), but within each university, there were no differences between the oral and written feedback groups (p>.20).CONCLUSIONS: No differences were observed between the oral and written feedback groups. In attempting to provide better feedback to their residents, medical educators may better apply their efforts to other aspects, such as the frequency of their feedback, rather than the form of its delivery.

Telephone Medicine for Internists

The role of the telephone in medical practice is important, but often problematic. Mistakes in telephone diagnosis and triage can have severe consequences. An effective office system can reduce liability risks, and in some cases telephone contact can substitute for office visits. Internists feel unprepared to provide telephone care. Therefore, residency education needs to focus on documentation, consultant availability, and performance feedback. Research should focus on improving outcomes, reimbursement issues, and technologic advances. This article describes internists’ telephone interactions with ambulatory patients, preparation for telephone medicine, and aspects of office telephone systems and makes comparisons with other primary care fields.

The patient panel conference experience: what patients can teach our residents about competency issues.

Purpose In 2007, the Scott & White/Texas A&M HSC College of Medicine began requiring all internal medicine residents to attend quarterly patient panel conferences, during which former Scott & White patients speak frankly about their inpatient and outpatient experiences. The main purpose of this mixed-methods pilot study was to determine whether residents’ competency education could be enhanced via the conferences. Method Of the 54 internal medicine residents in the residency program, 31, 39, and 41 participated in three patient panel conferences, respectively, between December 2007 and August 2008. Each resident completed an assessment that included a reflection on his or her own practice and the identification of competency issues highlighted by patients’ oral narratives. Content analyses of responses to open-ended questions were performed. Consensus on themes was reached. Descriptive statistics were run on quantitative data. Results Six themes were identified: improve communication with patients/families, improve patient care, improve professional behaviors, empathize with patients/families, display sensitivity to patients’/families’ needs/concerns, and recognize system issues. When asked if the conference highlighted competency problems, residents answered “agree” or “strongly agree” as follows: 82% for professionalism, 82.9% for systems-based practice, 85.2% for interpersonal and communication skills, and 84.4% for patient care. The majority were able to provide examples of competency issues. Conclusions The patient panel conference experience was a powerful mechanism for enhancing competency education. The conferences were an effective means of presenting real-life examples of systems issues in the context of a hospital system.

Medical student abuse from multiple perspectives

F or decades, surveys of graduating medical students have shown distressingly similar frequencies of perceived abuse, which can exceed 50 per cent. Prior studies have documented that women and students from minority ethnic groups are more likely to suffer abuse. Clinical rotations are the most likely situation in which abuse occurs, with internal medicine, midway through clinical rotations, demonstrating the most frequent abuse.

Exploring future models of primary care for Texas

Purpose The purpose of this study is to identify best practices for innovative primary care models and to describe a potential future primary care (PC) model for Texas to address the burden of chronic disease in a population-based approach. Design/methodology/approach A systematic literature review was conducted and identified 1,880 published records through PubMed using 26 search terms. After abstract and full-text review, 70 articles remained as potential models. Findings Although there is already a severe shortage of physicians in Texas, emerging practice patterns and choices among physicians are likely to erode access to primary care services in the state. Health-care leaders are encouraged to consider models such as complex adaptive systems for team-based care, pharmacist hypertension care management program and combined nurse-led care management with group visit structure. Research limitations/implications As with any study, this research has its limitations; for example, models that might work in one state, or under a unique state-funded academic medical center, might not be “do-able” in another state within the nuances of a different funding mechanism. Practical implications Results of this research provide a model for implementing IPCM for the state of Texas first and will guide IPCM planning and implementation in other states. Originality/value This study is “land grant-centric” and focused on carrying out the mission of a major, top-tier research university with an emerging college of medicine at an academic medical center.