Raymond H. Curry

The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters

OBJECTIVE To assess physician-patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. DESIGN An exploratory, observational study involving analysis of videotaped physician-patient encounters, questionnaires, and medical-record reviews. SETTING General internal medicine practice at an academic medical center. PARTICIPANTS Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). MAIN OUTCOME MEASURES Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. RESULTS Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patients agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patients life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. SUMMARY An EMR system may enhance the ability of physicians to complete information-intensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified.

The Use of Electronic Medical Records

OBJECTIVE To assess physician-patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. DESIGN An exploratory, observational study involving analysis of videotaped physician-patient encounters, questionnaires, and medical-record reviews. SETTING General internal medicine practice at an academic medical center. PARTICIPANTS Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). MAIN OUTCOME MEASURES Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. RESULTS Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patients agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patients life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. SUMMARY An EMR system may enhance the ability of physicians to complete information-intensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified.

Educating health care professionals to care for patients with disabilities.

THE US SURGEON GENERAL’S CALL TO ACTION TO IMprove the Health and Wellness of Persons With Disabilities was released in 2005 on the 15th anniversary of the Americans With Disabilities Act. The report noted increasing evidence that individuals with disabilities have worse health status than those without disabilities and that resources for persons with disabilities to maintain health, prevent secondary conditions, and optimize wellness are inadequate. The failure of medical education programs to teach concepts of disability was identified as a root cause, and educators were encouraged to “increase knowledge among health care professionals and provide them with tools to screen, diagnose, and treat the whole person with a disability with dignity.” Professional education about disability is a critical element in achieving quality health care, and having core competencies for health care professions education about patients with disabilities may help to achieve these goals. The reality that disability is a universal aspect of human experience, affecting nearly everyone at some point in his or her life span, is critical to the development of these core competencies. Following this principle of universality, disabilityrelated learning objectives should be integrated, insofar as is possible, into existing standards, competencies, and curricular formats. New and distinct curricular components should then address any critical gaps. This approach resonates with the perspective of many health care professions educators involved in disability issues: it holds a direct analogy to the principles of “universal design” in the physical environment, which encourages “the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design.” For every existing core competency in medical school and residency curricula (eg, interpersonal and communication skills, systems-based practice), health care professions educators should first ensure that the learning objectives for this core competency address the issues and needs of the broadest population. The second task then becomes identifying additional concepts and principles of care that are specific to disability and caring for persons with disabilities. Consider, through this lens, a curriculum in patientclinician communication. Its general principles, such as maintenance of eye contact when communicating, have implications for the care of patients with disabilities that should be made explicit. These would include, for example, sitting down to speak eye-to-eye with a wheelchair user or talking directly to a hearing-impaired person, rather than to that person’s sign language interpreter. Beyond these basics, this curriculum also should include skills specific to communicating effectively with persons with speech or language impairments, intellectual disabilities, and physical or sensory disabilities (such as the use of pictorial boards, assistive communications technologies, Braille or large print, and TTY machines or telephone relay operators).

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.

The evolution of courses in professional skills and perspectives for medical students.

A number of medical schools substantially revised their curricula in response to the GPEP Report, issued by the Association of American Medical Colleges in 1984. One of the most important areas of change has been in the way students are introduced to the professional skills and perspectives they will need to practice clinical medicine. A number of schools have recently developed interdisciplinary courses to accomplish this goal. Such courses may differ in scheduling, format, and focus, but they share a commitment to broadening skills and perspectives through experiential learning and small-group work. Most of these courses span the entire first two years of the curriculum, and some extend into the third and fourth years, blurring the line between the “preclinical” and “clinical” years. The near-simultaneous, largely independent introduction of major courses of this type into the curricula of some medical schools has gone largely unreported in the literature. This overview article discusses the origins of these courses and reviews the scope of the curricula now in place. Among the most comprehensive programs are those at Northwestern University, Oregon Health Sciences University, the University of California, Los Angeles, and the University of Nebraska, each of which is described and discussed in the following papers.

The content of internal medicine residency training and its relevance to the practice of medicine - Implications for primary care curricula

Using survey items from Kern et al. (1985), 192 former residents rated their preparation in, and the importance of, three content areas of their residency training (“basic skill and knowledge areas,” “allied medical disciplines,” and “areas related to the practice of medicine”). Mean ratings replicated those reported by Kern et al. (r=0.70 to 0.97, p<0.004). Using additional data about current practice patterns, ratings by general internists were compared with ratings by subspecialists. Both groups identified basic skill and knowledge areas as most important and felt that many areas related to practice management had been underempbasized. Most allied medical disciplines, however, were more important to generalists. Exposure to non-internal medicine areas seems important for residents considering a primary care career, but not for those considering subspecialization. However, all residents may benefit from increased emphasis on basic clinical skills and practice management. Program directors may want to address these issues, given the recent decline in applications to internal medicine programs.

North American medical schools' experience with and approaches to the needs of students with physical and sensory disabilities.

Purpose To determine the nature and frequency of impairments and related underlying conditions of medical students with physical and sensory disabilities (PSDs), and to assess medical schools’ use of relevant publications in setting admission criteria and developing appropriate accommodations. Method A 25-item survey addressed schools’ experiences with students known to have PSDs and their related policies and practices. The survey instrument was directed to student affairs deans at all 163 accredited American and Canadian medical schools. The authors limited the survey to consideration of PSDs, excluding psychiatric, cognitive, and learning disabilities. Results Eighty-six schools (52.8%) responded, representing an estimated 83,327 students enrolled between 2001 and 2010. Of these students, 0.56% had PSDs at matriculation and 0.42% at graduation. Although 81% of respondents were familiar with published guidelines for technical standards, 71% used locally derived institutional guidelines for the admission of disabled applicants. The most commonly reported accommodations for students with PSDs included extra time to complete tasks/exams (n = 62), ramps, lifts, or accessible entrances (n = 43), and dictated/audio-recorded lectures (n = 40). All responding schools required students’ demonstration of physical examination skills; requirements for other technical skills, with or without accommodations, varied considerably. Conclusions The matriculation and graduation rates of medical students with PSDs remain low. The most frequent accommodations reported were among those required of any academic or clinical setting by the Americans with Disabilities Act. There is a lack of consensus regarding technical standards for admission, suggesting a need to reexamine this critical issue.

Technical standards for the education of physicians with physical disabilities: perspectives of medical students, residents, and attending physicians.

VanMatre RM, Nampiaparampil DE, Curry RH, Kirschner KL: Technical standards for the education of physicians with physical disabilities: Perspectives of medical students, residents, and attending physicians. Am J Phys Med Rehabil 2004;83:54–60. ObjectiveThis pilot study assessed the opinions of medical students, residents, and attending physicians regarding the technical standards for medical school admission and the competencies required of graduates in the context of physical disability issues. DesignStudents, residents, and faculty from all specialties at a major academic medical center were surveyed regarding the concept of the “undifferentiated graduate;” the relative importance of motor, sensory, observation, and communication skills; the importance of specific technical skills; and the use of physician extenders and other accommodations to fulfill technical standards. ResultsRespondents placed higher importance on observation and communication skills compared with motor skills. Of respondents, 69.8% either disagree or strongly disagree with the idea that a medical student should be an undifferentiated candidate possessing all the technical skills necessary to enter any specialty. ConclusionsTechnical skills used in interpretation and observation were more important to respondents than those technical skills that are purely procedural. Respondents largely rejected the concept of the undifferentiated graduate. Although statistical analyses are of limited reliability because of low response rates, this study represents the most extensive sampling to date of medical professionals’ opinions on these issues. Respondents’ narrative comments also provided valuable perspectives.

Use of learning contracts in an office-based primary care clerkship.

This paper describes implementation of the learner‐centred learning goal within the primary care clerkship at a Midwestern, United States medical school.

Patient, physician & society: Northwestern University Medical School.

Northwestern University Medical Schools Patient, Physician & Society (PPS) course was introduced in 1993 as part of a complete restructuring of the first- and second-year curriculum. The PPS course meets two afternoons per week throughout the first two years, with one afternoon focusing on the relationship between patients and physicians and the other on that between physicians and society. The course is designed to provide a comprehensive, integrated introduction to professional skills and perspectives. Fourteen distinct curricular units address personal and professional ethics, medical humanities, behavioral sciences, physician-patient communication, physical diagnosis and clinical reasoning, health services organization and financing, preventive medicine, and the health of vulnerable groups. Health promotion as a primary goal of medicine is an underlying theme throughout the course. Active and interactive learning formats afford many opportunities for personal reflection and discussion. The overall response to the course has been positive, and survey data indicate that students completing PPS report more progress toward the schools fundamental educational goals than do students who had progressed through the first two years before the new curriculum was introduced. Still, a number of students are clearly uncomfortable with educational strategies that give them responsibility for finding answers on their own. Contrasts between PPS and the basic science courses--in content, presentation, and evaluation--highlight the importance of coordinating and integrating the overall medical school curriculum. Plans for enhancing the course include focusing on faculty development and student evaluation, as well as explicitly extending PPS material into the clerkship years.