Warren J. Ferguson

Patient health status and appointment keeping in an urban community health center

This study examines the relationship between patient health status and the likelihood of missing appointments in a community health center serving low-income patients. Medical records of 465 adult patients scheduled to be seen during one week in February 1999 were audited for an 18-month period. Seventy-three percent of patients failed to keep one or more appointments; 43% missed one or two; 30% missed three or more. Health status measures significantly associated with missing appointments included depression (p = 0.03), anxiety/panic disorder (p = 0.03), and using tobacco (p = <0.001). Linear regression analysis indicated that the number of appointments scheduled and of diagnosed psychological conditions, as well as patient age were significant predictors of missed appointments. Patient appointment keeping is predictable; definable, measurable characteristics of patients can contribute to setting priorities for customizing interventions.

Development and implementation of an objective structured teaching exercise (OSTE) to evaluate improvement in feedback skills following a faculty development workshop

Background: Faculty development programs focusing on teaching have become widespread. Purpose: Despite the popularity of such programs, evidence as to their effectiveness is limited. This article reports on the development of an objective structured teaching exercise (OSTE) and its pilot implementation in an evaluation of a faculty development program module. A written test intended to measure feedback skills was also developed and pilot tested. Methods: A separate-sample, pretest-posttest design was used to pilot test both instruments. Results: The results showed some evidence of significant differences between groups tested preworkshop and postworkshop. Higher scores were observed for the posttest group compared to the pretest group only for OSTE items focusing on prioritizing and limiting the amount of feedback given at one time and on action planning. Conclusions: Results suggest that an OSTE may be sensitive to changes in preceptor skill level for skills that are relatively easy to incorporate immediately into practice. Lack of differences in other skill areas may be due to lack of sensitivity of the measure or to need for practice and reflection before changes in performance on other feedback skills are evident.

Community preceptors' views of their identities as teachers

Purpose Community physicians are increasingly being recruited to teach medical students and residents, yet there has been little research about how they think of themselves as teachers or what factors contribute to “teacher identity.” Physicians who think of themselves as teachers may be more likely to enjoy teaching, to teach more, and to be recognized by students and other faculty as good teachers. Identifying factors that enhance teacher identity may be helpful for the recruitment and retention of high-quality community faculty. Method Thirty-five experienced community preceptors were audiotaped in five structured focus groups in April 2001, answering a series of questions about their teacher identity. Responses were qualitatively analyzed for evidence of themes. Results “Feeling intrinsic satisfaction” was the most common theme that emerged from the tapes. Preceptors also identified that “having knowledge and skill about teaching” and “belonging to a group of teacher” enhanced their roles as teachers. “Being a physician means being a teacher,” “feeling a responsibility to teach medicine,” and “sharing clinical expertise” also emerged as important themes. Although a group of participants were interested in “receiving rewards for teaching,” rewards did not need to be financial compensation. For some, genuine recognition for their efforts by the medical school, particularly in the form of faculty development opportunities, constituted reward and recognition for teaching. Conclusions Community physicians described a variety of factors that contribute to their identity as teachers. Faculty development programs offer opportunities to strengthen teacher identity and foster relationships between teaching programs and community-based faculty.

Developing Culturally Competent Community Faculty: A Model Program

The Liaison Committee on Medical Education recently set standards for cultural diversity training as part of the medical school curriculum. To the authors’ knowledge, this is the first description of a faculty-development program designed to develop the capacity of the clinical faculty to integrate culture and advocacy education into clinical training. The paper describes the first two years of the development of an ongoing cultural competence curriculum that has been integrated into the training of community preceptors from 13 medical schools in New England and New York. The training, entitled “Teaching the Culture of the Community,” consists of four 2.5-hour modules that include interactive lectures and small-group role-play exercises on cultural needs assessment, patient-centered interviewing, feedback on cultural issues and use of the community to enhance cultural understanding. The 137 participants in the first two years of the program (1999–00 and 2000–01) reported a high level of acceptance of the curriculum. In the second year, the program began to document participants’ self-reported “intention to change” in relation to the cultural competence curriculum. Many participants reported plans to change aspects of their clinical care and their teaching practices. Intentions to change were most frequently expressed in the context of content on effective communication skills. In summary, cultural competency training has been successfully integrated into an existing faculty-development program for community-based preceptors.

Recruitment and Retention of Primary Care Physicians at Community Health Centers: A Survey of Massachusetts Physicians

As the backbone of the safety-net system, community health centers (CHCs) provide access to essential services, yet contend with high provider turnover. Using an online survey, primary care physicians (PCPs) at 62 Massachusetts League of Community Health Centers member sites were queried about recruitment and retention factors. Nearly 300 (n=294) PCPs representing 46 CHCs completed the survey. Female physicians, those practicing in the greater Boston area, and those in practice for 10 or more years reported a higher likelihood of remaining in a CHC. Additional factors included: residency preparedness to practice in CHCs; the interview process; and satisfaction with the CHCs mission, patient diversity and current compensation. With the expansion of CHCs, attention must be paid to the PCP workforce. These survey results can inform advocates, leaders, policymakers, and educators regarding workforce initiatives and practice redesign. Once a commitment is made to caring for CHC patients, if this commitment is sustained, retention is good.

Correctional Health Curriculum Enhancement Through Focus Groups

Background: Little has been published describing curricular experiences in correctional health (CH). Purposes: Our goal is to articulate a curriculum cognizant of the special needs of the correctional health care worker. Methods: We conducted focus groups with nurses, nurse practitioners, physician assistants, and physicians focused on content crucial to prepare competent medical professionals committed to careers in correctional health. Results: Six main themes emerged from the data, which were used to confirm and add to the growing curriculum on correctional health used in our universitys correctional health electives. The themes are (a) characteristics of the population being served; (b) prevalent conditions requiring clinical expertise; (c) public health opportunities in correctional facilities; (d) ethical considerations; (e) medical-legal issues; and (d) the CH system, structure, and administration. Conclusions: The successful provision of health care in correctional settings requires specialized knowledge, skills, and awareness not typically available in other health care training settings.

Initial testing of an instrument to measure teacher identity in physicians

Background: A previous study described 7 elements of teacher identity: intrinsic satisfaction from teaching, knowledge and skill about teaching, belonging to a community of teachers, receiving rewards for teaching, believing that being a doctor means being a teacher, feeling a responsibility to teach, and sharing clinical expertise. Purpose: To conduct the initial testing of an instrument to measure the 7 elements of teacher identity in clinical educators and to consider the potential applications of such an instrument. Methods: A 37-item questionnaire was mailed to 153 preceptors of preclinical students. Categories reflected the elements of teacher identity listed here. Demographic data were collected. Means, alphas, ANOVAs, and paired t tests were calculated. Results: Of 153 preceptors, 127 (83%) completed the questionnaire. Cronbachs alpha for the overall scale and several subscales were high. Salaried physicians and those who had completed a faculty development program scored significantly higher on several subscales than physicians who volunteered to teach or who did not have faculty development. Conclusions: This study provides preliminary evidence that teacher identity can be measured and that preceptors do not respond as a homogeneous group. Assessing teacher identity may be helpful to medical schools looking to identify and support physicians who teach.

Behind bars: the compelling case for academic health centers partnering with correctional facilities.

Academic health centers (AHCs), particularly those that are publicly funded institutions, have as their mission the treatment of disadvantaged populations, the training of the next generation of clinicians, and the development and dissemination of new knowledge to reduce the burden of disease and improve the health of individuals and populations. Incarcerated populations have the most prevalent and acute disease burden and health disparities in the United States, even in comparison with inner-city populations. Yet, only a small proportion of AHCs have reached out to incarcerated populations to fulfill their mission. Those AHCs that have partnered with correctional facilities have overcome concerns about the value and popularity of “training behind bars”; the cost, liability, and pragmatics of caring for a medically complicated population; and the viability of correctional health research and extramural research funding. They have done so to great benefit to patients, students, and faculty. Partnering with correctional facilities to provide health care offers opportunities for AHCs to fulfill their core missions of clinical service, education, and research, while also enhancing their financial stability, to the benefit of all. In this Commentary, the authors discuss, based on their experiences, these concerns, how existing partnerships have overcome them, and the benefits of such relationships to both AHCs and correctional facilities.

Relationship between self-assessed and tested non-English-language proficiency among primary care providers.

Background:Individuals with limited English proficiency experience poor patient-clinician communication. Most studies of language concordance have not measured clinician non–English-language proficiency. Objectives:To evaluate the accuracy of the self-assessment of non–English-language proficiency by clinicians compared with an oral proficiency interview. Subjects:Primary care providers (PCPs) in California and Massachusetts. Measures:PCPs first completed a self-assessment of non–English-language proficiency using a version of the Interagency Language Roundtable (ILR) Scale, followed by the Clinician Cultural and Linguistic Assessment (CCLA), a validated oral proficiency interview. We used nonparametric approaches to analyze CCLA scores at each ILR scale level and the correlation between CCLA and ILR scale scores. Results:Sixteen PCPs in California and 51 in Massachusetts participated (n=67). Participants spoke Spanish (79%), followed by Cantonese, Mandarin, French, Portuguese, and Vietnamese. The respondents self-assessed as having “excellent” proficiency 9% of the time, “very good” proficiency 24% of the time, “good” proficiency 46% of the time, “fair” proficiency 18% of the time, and “poor” proficiency 3% of the time. The average CCLA score was 76/100. There was a positive correlation between self-reported ILR scale and CCLA score (&sgr;=0.49, P<0.001). The variance in CCLA scores was wider in the middle categories than in the low or high ILR categories (P=0.003). Conclusions:Self-assessment of non–English-language proficiency using the ILR correlates to tested language proficiency, particularly on the low and high ends of the scale. Participants who self-assess in the middle of the scale may require additional testing. Further research needs to be conducted to identify the characteristics of PCP whose self-assessments are inaccurate and, thus, require proficiency testing.

A longitudinal study of multicultural curriculum in medical education

Objectives To evaluate impact a multicultural interclerkship had on students’ perception of knowledge, interview skills, and empathy towards serving culturally diverse populations and role student demographics played in learning. Methods Data extracted from students’ self-reported course evaluations and pre/post questionnaires during multiculturalism interclerkship across 11 academic years. Inquired students’ opinion about four areas: effectiveness, small group leaders, usefulness, and overall experience. Subscale and item ratings were compared using trend tests including multivariate analyses. Results During studied years, 883 students completed course evaluation with high overall mean rating of 3.08 (SD=0.45) and subscale mean scores ranging from 3.03 to 3.30. Trends in three of four subscales demonstrated clear uptrend (p<0.0001). Positive correlations between ratings of leaders and “usefulness” were observed (p<0.0001). Pre/post matched dataset (n=967) indicated majority of items (19/23) had statistically significant higher post interclerkship ratings compared to pre scores with nine of 19 having statistically significant magnitudes of change. Questionnaire had high overall reliability (Cronbach alpha=0.8), and item-to-group correlations ranged from 0.40 to 0.68 (p <0.0001). Conclusions By increasing students’ exposure and interaction with diverse patients, their knowledge, attitude, and skills were increased and expanded in positive manner. These findings might inform those who are interested in enhancing this important competence. This is especially true given increasing scrutiny this global topic is receiving within and across healthcare professions around the world.