Sandy G. Smith

Barriers to effective teaching

Medical school faculty members are charged with the critical responsibility of preparing the future physician and medical scientist workforce. Recent reports suggest that medical school curricula have not kept pace with societal needs and that medical schools are graduating students who lack the knowledge and skills needed to practice effectively in the 21st century. The majority of faculty members want to be effective teachers and graduate well-prepared medical students, but multiple and complex factors-curricular, cultural, environmental, and financial-impede their efforts. Curricular impediments to effective teaching include unclear definitions of and disagreement on learning needs, misunderstood or unstated goals and objectives, and curriculum sequencing challenges. Student and faculty attitudes, too few faculty development opportunities, and the lack of an award system for teaching all are major culture-based barriers. Environmental barriers, such as time limitations, the setting, and the physical space in which medical education takes place, and financial barriers, such as limited education budgets, also pose serious challenges to even the most committed teachers. This article delineates the barriers to effective teaching as noted in the literature and recommends action items, some of which are incremental whereas others represent major change. Physicians-in-training, medical faculty, and society are depending on medical education leaders to address these barriers to effect the changes needed to enhance teaching and learning.

Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making.

BackgroundAlthough chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD.MethodsWe administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision.ResultsMore than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24).ConclusionsIn this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.

The minority student voice at one medical school: lessons for all?

Purpose Although the minority population of the United States is projected to increase, the number of minority students in medical schools remains stagnant. The University of Chicago Pritzker School of Medicine (PSOM) matriculates students underrepresented in medicine (URM) above the national average. To identify potential strategies through which medical schools can support the success of URM medical students, interviews with URM students/graduates were conducted. Method Students/recent graduates (within six years) who participated in this study self-identified as URMs in medicine and were selected for participation using random quota sampling. Participants completed a semistructured, qualitative interview in 2009–2010 about their experiences at PSOM. Key themes were identified and independently analyzed by investigators to ensure intercoder agreement. Results Participants identified five facets of their medical school experiences that either facilitated or hindered their academic success. Facilitators of support clustered in three categories: the collaborative learning climate at PSOM, the required health care disparities course, and student body diversity. Inhibitors of support clustered in two categories: insufficiently diverse faculty; and expectations—from self and others—to fulfill additional responsibilities, or carry a disproportionate burden. Conclusions Intentional cultivation of a collaborative learning climate, formal inclusion of health care disparities curriculum, and commitment to fostering student body diversity are three routes by which PSOM has supported URM students. Additionally, recognizing the importance of building a diverse faculty and extending efforts to decrease the disproportionate burden and stereotype threat felt by URM students are institutional imperatives.

Driving Deeper Learning by Assessment : An Adaptation of the Revised Bloom's Taxonomy for Medical Imaging in Gross Anatomy

RATIONALE AND OBJECTIVES As medical imaging continues to grow as a central modality by which physicians of all specialties visualize anatomy, so, too, is its role in medical student education. However, no study to our knowledge has attempted to categorize the necessary cognitive skills. Here, we assess a tool to identify those skills and their possible hierarchical nature that reflects deeper understanding of radiological anatomy. MATERIALS AND METHODS We adapted the revision of Blooms Taxonomy of Educational Objectives to create examination questions and teaching points for normal radiological anatomy in a medical anatomy course in 2008. All six previously established levels of cognitive processes were adapted, ranging from Remembering to Create. Reliability and validity were assessed. RESULTS Of 102 eligible students, 98 (98%) consented to participate, and 108 examination questions were assessed. Cronbach α assessing reliability ranged from poor (.197) to moderate (.571) with most categories being moderate. Score means for the levels of cognitive processes were statistically distinct [F(4, 102) = 180.63, P < .001] and tended to decrease as the level of cognitive process increased [Spearman ρ(5) = -.800, P = .104], consistent with a valid hierarchical structure. CONCLUSIONS A radiological anatomy adaptation of the revised taxonomy demonstrated generally adequate reliability and acceptable validity to establish evaluations that test different depths of cognitive processes. This is a critical first step to create a fundamental curricular tool by which medical imaging education-both normal and pathological-may be taught and assessed in the future.

Direct correlation of radiologic and cadaveric structures in a gross anatomy course

Background: Radiologic imaging is increasingly utilized as supplemental material in preclinical gross anatomy courses, but few studies have investigated its utility as a fully integrated instructional tool. Aims: Establish the benefit of a teaching method that simultaneously correlates cadaveric and radiologic structures for learning human anatomy. Method: We performed a mixed-methods randomized controlled trial and one-way cross-over study comparing exam grades and subjective student perception in a gross anatomy course. The intervention consisted of daily direct correlation small group sessions in which students simultaneously identified and correlated radiologic and cadaveric structures. The control method utilized identical laboratory and teaching conditions but students did not simultaneously correlate structures. Spatial relationships of structures within each respective media (gross or radiologic) were emphasized in both groups. Results: No significant differences in radiology, gross, or written exam scores were observed between the intervention and control groups. The cross-over group preferred the intervention and control methods equally. The correlation teaching sessions ranked equally with active dissection as the most important instructional components of the course. Conclusion: Direct, simultaneous correlation of radiologic and cadaveric structures did not affect exam scores or student preference but helped students understand anatomical concepts in comparison with other course components.

PHYSICIAN REFERRAL DECISIONS FOR OLDER CHRONIC KIDNEY DISEASE PATIENTS: A PILOT STUDY OF GERIATRICIANS, INTERNISTS, AND NEPHROLOGISTS

disorders. In an inner-city hospital study of patients aged 60 and older, 2% were positive for cocaine. This was a much higher prevalence than the NHSDA survey of 0.6% in patients aged 65 and older. Understanding the patterns of illegal drug use in older individuals is important from several standpoints. Cocaine users are more likely also to smoke tobacco and drink alcohol than those who do not use cocaine; the combination of cocaine, tobacco, and alcohol can further and synergistically exacerbate underlying medical conditions. Causes of illegal drug use in older adults has been attributed to stressful late-life events, loss of productive social roles, loneliness, drinking habits acquired in early life, and the absence of supportive social relationships. Because cocaine has been clearly implicated in cardiovascular disease, older patients should also be queried about such usage. Different geographic areas, ethnicities, and socioeconomic groups all require further study. It is apparent from reviewing the literature that cocaine abuse in older adults is underscreened. Proper counseling and treatment for substance dependence will not be provided if the problem is not identified. Many physicians do not focus on drug use history in a geriatric population. This is a dangerous trend that may stem from prejudices that this population ‘‘ages out’’ of abusing illicit substances. There is a high prevalence of psychiatric disorders, particularly depression, in older adults and a known link with drug abuse. The overall trend is for a rise in the prevalence of cocaine use, and thus an expected similar rise in the older population is likely. It is also likely that this problem is much less recognized in older adults because of its relative infrequency. Moreover, the statistics seem to underestimate the number of patients affected. Until there is greater appreciation of this problem and the underreporting bias is eliminated, it is likely that the abuse of cocaine by older adults will continue to be an ‘‘invisible epidemic.’’