Sondra Zabar

A Randomized Trial of Teaching Clinical Skills Using Virtual and Live Standardized Patients

AbstractBACKGROUND: We developed computer-based virtual patient (VP) cases to complement an interactive continuing medical education (CME) course that emphasizes skills practice using standardized patients (SP). Virtual patient simulations have the significant advantages of requiring fewer personnel and resources, being accessible at any time, and being highly standardized. Little is known about the educational effectiveness of these new resources. We conducted a randomized trial to assess the educational effectiveness of VPs and SPs in teaching clinical skills. OBJECTIVE: To determine the effectiveness of VP cases when compared with live SP cases in improving clinical skills and knowledge. DESIGN: Randomized trial. PARTICIPANTS: Fifty-five health care providers (registered nurses 45%, physicians 15%, other provider types 40%) who attended a CME program. INTERVENTIONS: Participants were randomized to receive either 4 live cases (n=32) or 2 live and 2 virtual cases (n=23). Other aspects of the course were identical for both groups. RESULTS: Participants in both groups were equivalent with respect to pre-post workshop improvement in comfort level (P=.66) and preparedness to respond (P=.61), to screen (P=.79), and to care (P=.055) for patients using the skills taught. There was no difference in subjective ratings of effectiveness of the VPs and SPs by participants who experienced both (P=.79). Improvement in diagnostic abilities were equivalent in groups who experienced cases either live or virtually. CONCLUSIONS: Improvements in performance and diagnostic ability were equivalent between the groups and participants rated VP and SP cases equally. Including well-designed VPs has a potentially powerful and efficient place in clinical skills training for practicing health care workers.

Physicians' attitudes about obesity and their associations with competency and specialty: A cross-sectional study

BackgroundPhysicians frequently report negative attitudes about obesity which is thought to affect patient care. However, little is known about how attitudes toward treating obese patients are formed. We conducted a cross-sectional survey of physicians in order to better characterize their attitudes and explore the relationships among attitudes, perceived competency in obesity care, including report of weight loss in patients, and other key physician, training, and practice characteristics.MethodsWe surveyed all 399 physicians from internal medicine, pediatrics, and psychiatry specialties at one institution regarding obesity care attitudes, competency, including physician report of percent of their patients who lose weight. We performed a factor analysis on the attitude items and used hierarchical regression analysis to explore the degree to which competency, reported weight loss, physician, training and practice characteristics explained the variance in each attitude factor.ResultsThe overall response rate was 63%. More than 40% of physicians had a negative reaction towards obese patients, 56% felt qualified to treat obesity, and 46% felt successful in this realm. The factor analysis revealed 4 factors–Physician Discomfort/Bias, Physician Success/Self Efficacy, Positive Outcome Expectancy, and Negative Outcome Expectancy. Competency and reported percent of patients who lose weight were most strongly associated with the Physician Success/Self Efficacy attitude factor. Greater skill in patient assessment was associated with less Physician Discomfort/Bias. Training characteristics were associated with outcome expectancies with newer physicians reporting more positive treatment expectancies. Pediatric faculty was more positive and psychiatry faculty less negative in their treatment expectancies than internal medicine faculty.ConclusionPhysician attitudes towards obesity are associated with competency, specialty, and years since postgraduate training. Further study is necessary to determine the direction of influence and to explore the impact of these attitudes on patient care.

Do Internists, Pediatricians, and Psychiatrists Feel Competent in Obesity Care?: Using a Needs Assessment to Drive Curriculum Design

BACKGROUNDPhysicians must effectively evaluate and treat obesity. To design a needs-driven curriculum intended to improve patient outcomes, physicians were surveyed about their self-perceived knowledge and skills.OBJECTIVEThe objective of this study was to determine the expressed needs of residents and faculty regarding obesity care training across three specialties.DESIGNThe study used a survey given to faculty and residents in General Internal Medicine, Pediatrics, and Psychiatry.METHODSSurvey questions were generated from comprehensive nutrition curriculum and clinical recommendations, administered online, and then organized around a validated behavioral health framework—the 5As (assess, advise, agree, assist, arrange). Analyses were conducted to evaluate differences in perceived knowledge and skills between specialties and across training levels.RESULTSFrom an overall response rate of 65% (65 residents and 250 faculty members), nearly 20% reported inadequate competency in every item with 48% of respondents reporting an inability to adequately counsel patients about common treatment options. Internists reported the lowest competency in arranging referrals and follow-up. Psychiatrists reported the lowest competency in assessment skills.CONCLUSIONSThis survey demonstrated a critical need for training in specific areas of obesity care. The proposed curriculum targets these areas taking into consideration observed differences across specialties.

Can professionalism be taught? Encouraging evidence

BACKGROUND Teaching and assessing the Accreditation Council for Graduate Medical Education (ACGME) competencies of Professionalism and Communication have proven to be a challenge for surgical residency training programs. This study used innovative pedagogic approaches and tools in teaching these two competencies. The purpose of this study was to determine whether the learners actually are assimilating and using the concepts and values communicated through this curriculum. METHODS A six-station Objective Structured Clinical Examination (OSCE) was designed using standardized patients to create varying Professionalism and Communication scenarios. The surgical resident learners were evaluated using these OSCEs as a baseline. The faculty then facilitated a specially designed curriculum consisting of six interactive sessions focusing on information gathering, rapport building, patient education, delivering bad news, responding to emotion, and interdisciplinary respect. At the conclusion of this curriculum, the surgical resident learners took the same six-station OSCE to determine if their professionalism and communication skills had improved. RESULTS The surgical resident learners were rated by the standardized patients according to a strict task checklist of criteria at both the precurricular and postcurricular OSCEs. Improvement in the competencies of Professionalism and Communication did achieve statistical significance (P = .029 and P = .011, respectively). CONCLUSIONS This study suggests that the Communication and Professionalism ACGME competencies can be taught to surgical resident learners through a carefully crafted curriculum. Furthermore, these newly learned competencies can affect surgical resident interactions with their patients positively.

Measuring the competence of residents as teachers.

Medical residents, frontline clinical educators, must be competent teachers. Typically, resident teaching competence is not assessed through any other means than gleaning learner’s comments. We developed, evaluated, and integrated into our annual objective structured clinical examination a resident teaching skills assessment using “standardized” students. Faculty observers rated residents using a customized 19-item rating instrument developed to assess teaching competencies that were identified and defined as part of our project. This was feasible, acceptable, and valuable to all 65 residents, 8 students, and 16 faculty who participated. Teaching scenarios have potential as reliable, valid, and practical measures of resident teaching skills.

A randomized trial of a brief multimedia intervention to improve comprehension of food labels.

OBJECTIVE Food label use is associated with better food choices, an essential part of the management of many chronic diseases. Previous studies suggest lack of comprehension of food labels. We studied a multimedia intervention to improve food label comprehension in a sample of low income patients in New York City. METHODS This randomized study took place at Gouverneur Healthcare Services from 2005 until 2007. The intervention group (n=29) received a Nutrition Facts Label pocket card and viewed a video explaining card use. The control group (n=27) received written materials. Participants completed a 12-item pre- and post-intervention nutrition food label quiz. Quiz scores were analyzed using repeated measures analysis of variance. RESULTS The intervention group had greater improvement on the quiz than the control group (p<0.001). There was a three way interaction by time with health literacy and treatment group where the greatest improvement occurred in patients with adequate health literacy in the intervention group (p<0.05). There was no improvement in patients with limited health literacy. CONCLUSION A multimedia intervention is an effective way to improve short-term food label comprehension in patients with adequate health literacy. Further research is necessary to improve understanding of food labels in patients with limited health literacy.

The stress of residency: recognizing the signs of depression and suicide in you and your fellow residents

BACKGROUND Stress, depression, and suicide are universal but frequently unrecognized issues for women and men in residency training. Stress affects cognitive and psychomotor performance both inside and outside of the operating room. Stress impairs the 2 key components of a surgeons responsibilities: intellectual judgment and technical skill. We hypothesized that the recognition of depression, substance abuse, failing personal relationships, and potential suicide is poor among surgeons. If residents can recognize the signs of stress, depression, and suicide among colleagues, we believe it will not only improve their quality of life but also may preserve it. METHODS We first determined baseline resident knowledge of the signs of surgical stress including fatigue; burn out; depression; physician suicide; drug and alcohol abuse; and their effects on family, friends, and relationships. We then developed a curriculum to identify these signs in first, second, third, and fourth year surgical residents were identified as the target learners. The major topics discussed were depression; physician suicide; drug and alcohol abuse; and the effects of stress on family, friends, and our goals. Secondary objectives included identifying major sources of stress, general self-awareness, understanding professional choices, and creating a framework to manage stress. Residents participated in an interactive seminar with a surgical facilitator. Before and after the seminar, a multiple-choice test was administered with questions to assess knowledge of the signs of stress (eg, fatigue, burn out, and depression). RESULTS Twenty-one residents participated in this study. Seventeen completed the pretest, and 21 participated in the interactive seminar and completed the post-test. The pretest revealed that surgical residents were correct in 46.8% (standard deviation [SD] = 25.4%) of their responses. The postseminar test showed an improvement to 89.7% (SD = 6.1%, P < .001, paired Student t test = 5.37). The same test administered 4 months later to 17 of the 21 learners revealed 76.9% (SD = 18.7%) correct answers, suggesting that the information had been internalized. Cronbach α was calculated to be .67 for the pretest and .76 for the post-test, suggesting a moderate to high degree of internal consistency. CONCLUSIONS Stress is a significant and regularly overlooked component of a surgeons life. Because its effects often go unrecognized, stress frequently remains unresolved. To prevent its associated consequences such as depression, substance abuse, divorce, and suicide, educating house staff about stress is crucial. This study suggests that the symptoms, causes, and treatment of stress among surgeons can be taught effectively to surgical resident learners.

''Oh! She Doesn't Speak English!'' Assessing Resident Competence in Managing Linguistic and Cultural Barriers

AbstractBACKGROUND: Residents must master complex skills to care for culturally and linguistically diverse patients. METHODS: As part of an annual 10-station, standardized patient (SP) examination, medical residents interacted with a 50-year-old reserved, Bengali-speaking woman (SP) with a positive fecal occult blood accompanied by her bilingual brother (standardized interpreter (SI)). While the resident addressed the need for a colonoscopy, the SI did not translate word for word unless directed to, questioned medical terms, and was reluctant to tell the SP frightening information. The SP/SI, faculty observers, and the resident assessed the performance. RESULTS: Seventy-six residents participated. Mean faculty ratings (9-point scale) were as follows: overall 6.0, communication 6.0, knowledge 6.3. Mean SP/SI ratings (3.1, range 1.9 to 3.9) correlated with faculty ratings (overall r=.719, communication r=.639, knowledge r=.457, all P<.01). Internal reliability as measured by Cronbach’s α coefficients for the 20 item instrument was 0.91. Poor performance on this station was associated with poor performance on other stations. Eighty-nine percent of residents stated that the educational value was moderate to high. CONCLUSION: We reliably assessed residents communication skills conducting a common clincal task across a significant language barrier. This medical education innovation provides the first steps to measuring interpreter facilitated skills in residency training.

A Novel Longitudinal Geriatric Medical Student Experience:: Using Teaching Objective Structured Clinical Examinations

It has previously been shown that medical students perform poorly when assessing older adults with recurrent falls. To address this and teach students about other geriatric syndromes, a standardized patient, played by one of nine actresses, aging during the course of an afternoon, was developed. The patient is first aged 75 with falls, then 80 with memory problems, then 82 with an acute confusional state. The third‐year students interact with the patient on a one‐to‐one basis. After seeing and examining her, the students write up the case and then meet with the supervising physician after each section to discuss the case. This intervention was well accepted, scoring 5.95 on a 7‐point Likert‐type scale. At the end of the clinical year, the students participated in an eight‐case clinical skills examination that included a 79‐year‐old man with falls. Using the actors checklists, the performances of the 42 medical students who had participated in the standardized patient experience were compared with those of the 128 who had not. Over the eight cases, there was no difference in the three domains of communication, information gathering, and physical examination, but in the geriatric case, the students who had participated in the experience performed significantly better in all three domains. The intervention students were also three times as likely to examine the subjects gait (60% vs 20%). A 3‐hour interactive session substantially improved specific geriatric competencies. One can only wonder what more dedicated time could accomplish.

Health Literacy: An Educationally Sensitive Patient Outcome.

ABSTRACTWe have previously proposed that by identifying a set of Educationally Sensitive Patient Outcomes (ESPOs), medical education outcomes research becomes more feasible and likely to provide meaningful guidance for medical education policy and practice. ESPOs are proximal outcomes that are sensitive to provider education, measurable, and linked to more distal health outcomes. Our previous model included Patient Activation and Clinical Microsystem Activation as ESPOs. In this paper, we discuss how Health Literacy, defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,” is another important ESPO. Between one-third and one-half of all US adults have limited health literacy skills. Providers can be trained to adopt a “universal precautions approach” to addressing patient health literacy, through the acquisition of specific skills (e.g., teachback, “chunking” information, use of plain language written materials) and by learning how to take action to improve the “health literacy environment.” While there are several ways to measure health literacy, identifying which measurement tools are most sensitive to provider education is important, but challenging and complex. Further research is needed to test this model and identify additional ESPOs.