Rebecca C. Henry

Curricular Change in Medical Schools: How to Succeed

Societys changing needs, advancing knowledge, and innovations in education require constant changes of medical school curricula. But successful curricular change occurs only through the dedicated efforts of effective change agents. This study systematically searched and synthesized the literature on educational curricular change (at all levels of instruction), as well as organizational change, to provide guidance for those who direct curricular change initiatives in medical schools. The focus was on the process of planning, implementing, and institutionalizing curricular change efforts; thus, only those articles that dealt with examining the change process and articulating the factors that promote or inhibit change efforts were included. In spite of the highly diverse literature reviewed, a consistent set of characteristics emerged as being associated with successful curricular change. The frequent reappearance of the same characteristics in the varied fields and settings suggests they are robust contributors to successful change. Specifically, the characteristics are in the areas of the organizations mission and goals, history of change in the organization, politics (internal networking, resource allocation, relationship with the external environment), organizational structure, need for change, scope and complexity of the innovation, cooperative climate, participation by the organizations members, communication, human resource development (training, incorporating new members, reward structure), evaluation, performance dip (i.e., the temporary decrease in an organizations performance as a new program is implemented), and leadership. These characteristics are discussed in detail and related specifically to curricular change in medical school settings.

Residents' attitudes towards and skills in counseling: using undetected standardized patients.

Objective:To identify the frequency and quality of certain prevention-oriented counseling skills of resident physicians and to compare these skills with the residents’ attitudes towards and knowledge about primary prevention.Design:Longitudinal descriptive study.Patients/participants:54 PGY-1-3 internal medicine and family practice residents enrolled in three training programs affiliated with Michigan State University’s College of Human Medicine.Intervention:Trainees’ attitudes towards and knowledge about certain prevention activities were captured by an instrument designed for this study using 127 Likert scales. Counseling skills were assessed with one of two standardized patients. Residents were unaware of the simulation, which occurred in their routinely scheduled ambulatory care setting. Audiotapes of the interactions were rated by blinded, independent raters. Residents had strong positive beliefs about the role of primary care physicians in counseling patients, high levels of knowledge about what the counseling should entail, and high self-assessment about the frequency and quality of their own counseling interventions. Skill levles, however, were at or below a level defined as minimally acceptable.Conclusion:Resident physicians’ skill levels, as measured in this study, are inadequate to accomplish routine counseling interventions in the primary care setting. These results suggest that more reliance should be placed on direct observation of physicians, ideally in nonreactive settings, for purposes of drawing conclusions about physician performance. Further, these results have implications for the training of students and residents in the area of counseling for prevention.

Efficacy of a one-month training block in psychosocial medicine for residents : a controlled study

Study objective:To determine the efficacy of a comprehensive, one-month psychosocial training program for first-year medical residents.Design:Nonrandomized, controlled study with immediate pre/post evaluation. Limited evaluation of some residents was also conducted an average of 15 months after teaching.Setting:Community-based, primary care-oriented residency program at Michigan State University (MSU).Subjects:All 28 interns from the single-track MSU residency program during 1986/87–88/89 participated in this required rotation; there was no dropout or instance of noncompliance with the study. In the follow-up study in 1989, all 13 available trainees participated. Of 20 untrained, volunteer controls, ten were second/third-year residents in the same program during 1986/87 and ten were interns from a similar MSU program in Kalamazoo, MI, during 1988/89.Teaching intervention:An experiential, skill-oriented, and learner-centered rotation with competency-based objects focused on communication and relationship-building skills and on the diagnosis and management of psychologically disturbed medical patients.Measurements and main results:The two subsets of the control group were combined because residents and training programs were similar and because means and standard deviations for the subsets were similar on all measures. By two-way analyses of variance (group×gender), the trainee group showed significantly greater gains (p<0.001) on questionnaires addressing knowledge, self-assessment, and attitudes; a mean of 15 months following training, there was no significant deterioration of attitude scores. All trainees were also able to identify previously unrecognized, potentially deleterious personal responses using a systematic rating procedure. Residents’ acceptance of the program was high.Conclusions:Intensive, comprehensive psychosocial training was well accepted by residents. It improved their knowledge, self-awareness, self-assessment, and attitudes, the latter improvement persisting well beyond training.

When do medical students become human subjects of research? The case of program evaluation.

Intense national dialogue exists around federal requirements protecting the rights of human subjects in clinical research. There is much less discussion surrounding protections for human subjects in such areas as evaluation research when the subjects are also students. Differential interpretation of 45 CFR 46 (the standing regulation on research involving human subjects) by institutional review boards (IRBs) leaves many confused about whether research using student data requires IRB review. At the heart of the uncertainty are “dual purpose activities,” for example, when student data from program evaluation or routine assessments subsequently become the basis for faculty scholarship that is disseminated as “generalizable knowledge” to the community of medical educators. The authors identify two factors that should be considered as institutions develop applications and interpretations of 45 CFR 46. First, medical educators should enter into dialogues with their IRBs to become more familiar with these regulations and their application in evaluation or assessment studies. Second, for reasons of professionalism, faculty should seek opportunities to model in their role as researchers those ethical behaviors that are central to an honest relationship between physician and patient. In the educational context this means faculty disclosure of how student data may be used by faculty in their own scholarship and determination of when student consent is needed. The authors also describe how one medical school addressed this thorny challenge with assistance from the university IRB and offer suggestions to improve institutional procedures.

Lessons learned from implementing multidisciplinary health professions educational models in community settings

This article addresses sustainability elements for multidisciplinary health professions education in communities. The results are based on a 5 year program involving multiple health professions education institutions in seven states within the USA. We offer observations and suggestions to others who plan and implement multidisciplinary programs for health professions educators. Our findings are based on the outcomes of the Community Partnerships in Health Professions Education (CPHPE) initiative funded by the W. K. Kellogg Foundation. Data sources included pre and post surveys of students and faculty, site visits, published evaluations and site reports, and a 2 year follow-up evaluation after the external funding phase. Elements of the partnership that facilitated the sustainability of the models were: leadership, complementary missions, curriculum that mirrors clinical community practice, change from outside in, partnership boards, and faculty development. Those elements that were barriers to sustaining the efforts were: professional identities and territorial boundaries, structural differences, costs, and unclear goals. The multidisciplinary components of the community partnership initiative were the most challenging. However, in most programs, they did succeed and are currently in place. By paying attention to the elements that enhance and detract from teaming, one can plan for more successful multidisciplinary education.

Evaluation of a faculty development program for family physicians.

Faculty development programs are frequently conducted for family physicians as a mechanism to train and retrain faculty. However, these programs are rarely subjected to comprehensive evaluations that assess outcomes other than participant satisfaction. This paper describes a comprehensive evaluation study that collected reaction, cognitive and behavioral data on participants in a faculty development program for family physicians. Data were collected using a variety of evaluations strategies and sources of data over a period of time from the first day of the program until 9 months following its completion. Results were consistent across measures and sources and indicated that the participants learned new cognitive content and applied knowledge and skills acquired during the program. Participants, their supervisors and the faculty development program faculty consistently reported high satisfaction with the program. Thus, the evaluation study demonstrated that the program was successful and had the desired i...

Teaching research skills: Development and evaluation of a new research program for residents

Since 1981, the internal medicine training program at Michigan State University has offered an elective research program for residents. Based on the literature and 10 years of experience in primary care faculty development, a research program was developed. It included (a) establishment of educational goals and resident expectations, (b) selection of a research director, (c) a structured research curriculum, (d) research meetings, (e) a research committee to review work, (f) protected time, and (g) a research presentation forum. The research program addressed the topics of critical reading skills, MEDLINE searching skills, basic research methodology, and scientific communication skills. Over the past 10 years, the residents’ scholarly activity has increased greatly as measured by the number of their presentations to state or national scientific meetings, their state and national awards, and their publications.

A course component to teach interviewing skills in informing and motivating patients

In the present study, the authors implemented and evaluated a course component to teach three types of interviewing skills: giving information to patients, handling emotions on the part of patients, and motivating patients. The authors developed a seven-week course for second-year students that included identification and demonstration of explicit interviewing skills, practice with simulated patients, and feedback in a small-group setting. Thirty of the 104 students in the course were randomly selected for evaluation before and after the course. They showed statistically significant increases in their interviewing skills, based on ratings of videotaped interviews with simulated patients after the course, but did not change significantly in self-assessment of their level of confidence in aspects of conducting the interviews.

Between a rock and a hard place: finding a place for the OSCE in medical education.

For the longest time, assessing the competency of medical students was a relatively straightforward task. Written examinations were used to assess biomedical knowledge, faculty ratings were used to judge clinical competency, and national exams were used to determine promotion to the next phase of education. More recently, undergraduate medical education has had to accommodate advances in biomedical sciences, changes in the how health care is delivered, and shifts in societal expectations of physicians. Quite naturally, these same forces have required medical educators to reconsider how medical student competency is best assessed. The challenge has been to develop assessments both relevant to, and spanning the breadth of, medical practice. We have been cautioned that any approach must include assessments of what students know, as well as what they can do. To this end, much energy has focused on improving written examinations, particularly the psychometric properties of multiple choice questions for measuring knowledge and problem-solving. In contrast, deficiencies of faculty ratings related to their subjective scoring and lack of standardization have been largely ignored.

Teaching and storytelling: An ethnographic study of the instructional process in the college classroom

An ethnographic study was conducted which analyzed the complex teaching behaviors of a distinguished professor at a large university. Reputed to be a gifted instructor, his teaching was investigated through direct observation, videotaping, questionnaires and indepth interviews to determine specifically how the professor accomplished his teaching goals. A detailed descriptive account of teacher-student interaction is provided, as well as an analysis of why the instruction is successful from both perspectives. A major finding was that the instructor incorporated a storytelling technique to impart information and to involve students. This technique was repeatedly confirmed by students, teachers and investigators. Further, other teaching behaviors that promoted student learning were documented and analyzed. Finally, the implications of ethnographic research for understanding effective instruction is discussed.