Sigall K. Bell

Longitudinal pedagogy: a successful response to the fragmentation of the third-year medical student clerkship experience.

A longitudinal clerkship was designed at Harvard Medical School (HMS) in 2004–2005 to emphasize continuity, empathy, learner-centeredness, and patient-centered care. In 2005–2006, the curriculum was piloted with eight students who voluntarily enrolled in the third-year curriculum, which focused on longitudinal mentorship and feedback, interdisciplinary care, integration of clinical and basic science, and humanism in patient care. Eighteen traditional curriculum (TC) students at HMS who were comparable at baseline served as a comparison group. SHELF exams and OSCE performance, monthly and end-of-year surveys, and focus groups provided comparisons between pilot and TC students on their performance, perceptions, attitudes, and satisfaction. Pilot students performed as well as or better than their peers in standardized measures of clinical aptitude. They demonstrated statistically significant greater preservation of patient-centered attitudes compared with declining values for TC students. Pilot students rated the atmosphere of learning, effective integration of basic and clinical sciences, mentorship, feedback, clerkship satisfaction, and end-of-year patient-care preparedness significantly higher than TC students. The authors conclude that implementation of a longitudinal third-year curriculum, with only modest alterations in existing clinical training frameworks, is feasible and effective in meeting its stated goals. “Exposing” the hidden curriculum through specific longitudinal activities may prevent degradation of student attitudes about patient-centered care. Minimizing the disjointed nature of clinical training during a critical time in students’ training by providing a cohesive longitudinal curriculum in parallel to clinical clerkships, led by faculty with consistent contact with students, can have positive effects on both professional performance and satisfaction.

Clinical Management of Acute HIV Infection: Best Practice Remains Unknown

Best practice for the clinical management of acute human immunodeficiency virus (HIV) infection remains unknown. Although some data suggest possible immunologic, virologic, or clinical benefit of early treatment, other studies show no difference in these outcomes over time, after early treatment is discontinued. The literature on acute HIV infection is predominantly small nonrandomized studies, which further limits interpretation. As a result, the physician is left to grapple with these uncertainties while making clinical decisions for patients with acute HIV infection. Here we review the literature, focusing on the potential advantages and disadvantages of treating acute HIV infection outlined in treatment guidelines, and summarize the presentations on clinical management of acute HIV infection from the 2009 Acute HIV Infection Meeting in Boston, Massachusetts.

Talking with Patients about Other Clinicians' Errors

The authors discuss the challenges facing a clinician who discovers that her patient has been harmed by another health care workers medical error. They provide guidance to help clinicians and institutions disclose such errors to patients.

How trainees would disclose medical errors: educational implications for training programmes.

Medical Education 2011: 45: 372–380

Error disclosure: a new domain for safety culture assessment

Objective To (1) develop and test survey items that measure error disclosure culture, (2) examine relationships among error disclosure culture, teamwork culture and safety culture and (3) establish predictive validity for survey items measuring error disclosure culture. Method All clinical faculty from six health institutions (four medical schools, one cancer centre and one health science centre) in The University of Texas System were invited to anonymously complete an electronic survey containing questions about safety culture and error disclosure. Results The authors found two factors to measure error disclosure culture: one factor is focused on the general culture of error disclosure and the second factor is focused on trust. Both error disclosure culture factors were unique from safety culture and teamwork culture (correlations were less than r=0.85). Also, error disclosure general culture and error disclosure trust culture predicted intent to disclose a hypothetical error to a patient (r=0.25, p<0.001 and r=0.16, p<0.001, respectively) while teamwork and safety culture did not predict such an intent (r=0.09, p=NS and r=0.12, p=NS). Those who received prior error disclosure training reported significantly higher levels of error disclosure general culture (t=3.7, p<0.05) and error disclosure trust culture (t=2.9, p<0.05). Conclusions The authors created and validated a new measure of error disclosure culture that predicts intent to disclose an error better than other measures of healthcare culture. This measure fills an existing gap in organisational assessments by assessing transparent communication after medical error, an important aspect of culture.

The educational value of improvisational actors to teach communication and relational skills: Perspectives of interprofessional learners, faculty, and actors

OBJECTIVE To assess the educational value of improvisational actors in difficult conversation simulations to teach communication and relational skills to interprofessional learners. METHODS Surveys of 192 interprofessional health care professionals, and 33 teaching faculty, and semi-structured interviews of 10 actors. Descriptive statistics, Fishers exact test and chi-square test were used for quantitative analyses, and the Crabtree and Miller approach was used for qualitative analyses. RESULTS 191/192 (99.5%) interprofessional learners (L), and 31/33 (94%) teaching faculty (F) responded to surveys. All 10/10 actors completed interviews. Nearly all participants found the actors realistic (98%L, 96%F), and valuable to the learning (97%L, 100%F). Most felt that role-play with another clinician would not have been as valuable as learning with actors (80%L, 97%F). There were no statistically significant differences in perceived value between learners who participated in the simulations (47%) versus those who observed (53%), or between doctors, nurses, or psychosocial professionals. Qualitative assessment yielded five actor value themes: Realism, Actor Feedback, Layperson Perspective, Depth of Emotion, and Role of Improvisation in Education. Actors independently identified similar themes as goals of their work. CONCLUSIONS The value attributed to actors was nearly universal among interprofessional learners and faculty, and independent of enactment participation versus observation. Authenticity, feedback from actors, patient/family perspectives, emotion, and improvisation were key educational elements.

Let's Show Patients Their Mental Health Records

Should we health professionals encourage patients with mental illness to read their medical record notes? As electronic medical records and secure online portals proliferate, patients are gaining ready access not only to laboratory findings but also to clinicians’ notes.1 Primary care patients report that reading their doctors’ notes brings many benefits including greater control over their health care, and their doctors experience surprisingly few changes in workflow. 2 While patients worry about electronic records and potential loss of privacy, they vote resoundingly for making their records more available to them and often to their families.

Disclosure, Apology, and Offer Programs: Stakeholders’ Views of Barriers to and Strategies for Broad Implementation

CONTEXT The Disclosure, Apology, and Offer (DA&O) model, a response to patient injuries caused by medical care, is an innovative approach receiving national attention for its early success as an alternative to the existing inherently adversarial, inefficient, and inequitable medical liability system. Examples of DA&O programs, however, are few. METHODS Through key informant interviews, we investigated the potential for more widespread implementation of this model by provider organizations and liability insurers, defining barriers to implementation and strategies for overcoming them. Our study focused on Massachusetts, but we also explored themes that are broadly generalizable to other states. FINDINGS We found strong support for the DA&O model among key stakeholders, who cited its benefits for both the liability system and patient safety. The respondents did not perceive any insurmountable barriers to broad implementation, and they identified strategies that could be pursued relatively quickly. Such solutions would permit a range of organizations to implement the model without legislative hurdles. CONCLUSIONS Although more data are needed about the outcomes of DA&O programs, the model holds considerable promise for transforming the current approach to medical liability and patient safety.

Microethics: the ethics of everyday clinical practice.

Over the past several decades, medical ethics has gained a solid foothold in medical education and is now a required course in most medical schools. Although the field of medical ethics is by nature eclectic, moral philosophy has played a dominant role in defining both the content of what is taught and the methodology for reasoning about ethical dilemmas. Most educators largely rely on the case-based method for teaching ethics, grounding the ethical reasoning in an amalgam of theories drawn from moral philosophy, including consequentialism, deontology, and principlism. In this article we hope to make a case for augmenting the focus of education in medical ethics. We propose complementing the traditional approach to medical ethics with a more embedded approach, one that has been described by others as “microethics,” the ethics of everyday clinical practice.

Speaking Up About The Dangers Of The Hidden Curriculum

A medical student’s fear of raising questions endangered a patient. Here, as a resident, he explores the dangers of this “hidden curriculum” with his advisers.