Use of the ureteral access sheath during ureteroscopy in children.

PURPOSE: The use of ureteral access sheaths during ureteroscopy is common but there are sparse data on the safety and outcomes of ureteral access sheath use in children. We compared the outcomes of ureteroscopy with vs without a ureteral access sheath in children. MATERIALS AND METHODS: We retrospectively reviewed all ureteroscopy procedures for urolithiasis in patients younger than 21 years at our hospital from 1999 to 2009. The primary outcome was intraoperative complications. Secondary outcomes were postoperative hydronephrosis, emergency room visit/hospital readmission within 90 days, stone-free status and need for re-treatment. We analyzed associations of a ureteral access sheath with outcomes. RESULTS: A total of 34 boys and 62 girls with a mean age of 13 years underwent ureteroscopy. A ureteral access sheath was used in 40 of the 96 patients (42%). The mean stone burden was 9.6 mm. Median followup was 11 months (range 0.2 to 110). Intraoperative complication occurred in 7 cases, including perforation/extravasation in 4, a submucosal wire in 2 and stent migration in 1. Intraoperative complications were more common when a sheath was used (15% vs 2%, adjusted OR 8.2, 95% CI 1.3-50.9, p = 0.02). Postoperative hydronephrosis was observed in 7 of 73 cases (10%) but it was not significantly more common when a sheath was used. No ureteral stricture was identified. Sheath use was not associated with postoperative telephone calls, emergency room visits or rehospitalization. Although the stone-free rate tended to be higher in cases without a sheath (78% vs 59%, p = 0.09), this association was not significant in a multivariate model (p = 0.6). CONCLUSIONS: Although intraoperative complications occur more commonly during ureteroscopy with a ureteral access sheath, no increase in longer term adverse effects were observed. Future prospective studies of ureteral access sheath use in children with longer followup are warranted.

Personalized remedial intensive training of one medical student in communication and interview skills.

BACKGROUND: Medical students found to be deficient in communication and interview skills pose a difficult remediation challenge. There is no standard way to address such deficiencies. The authors describe the development and implementation of an intensive remedial curriculum. DESCRIPTION: A 2nd-year student found deficient in communication skills was held back for a year and paired with a clinical preceptor for intensive skills training, including a weekly precepted clinic, structured readings, standardized patient (SP) exercises, communications workshops, and end-of-year standardized clinical evaluations. EVALUATION: The student's self-assessment and the preceptor's assessments of communication skill gradually improved over the year. The student improved through a progression of SP exercises focusing on specific communication skills. The student passed a final evaluation exercise with an excellent rating from the SP and the preceptor. CONCLUSIONS: This multistrategy approach to improve communication skills can be applied to other students and in other institutions. Based on the Bayer Institute communication workshops and integrated coaching techniques, the material forms a framework to help deficient students to become proficient in communication and interviewing skills.

Improving medical students' communication with limited-literacy patients: project development and implementation.

BACKGROUND: Physicians may not realize that some of their patients have limited reading abilities. The AMC Cancer Research Center and the Primary Care Curriculum at the University of Colorado collaborated to develop and implement a project to teach medical students to identify and effectively communicate with limited-literacy patients regarding cancer screening. METHOD: The project incorporated two standardized-patient (SP) cases on cancer screening and literacy into the existing curriculum for second-year students. A small-group, interactive problem-based learning (PBL) case on breast cancer screening and literacy introduced the concept of communicating about cancer screening and literacy issues. A clinical practice examination on colorectal cancer screening and literacy was given at the end of the year. RESULTS: The collaborative project proved successful in incorporating literacy and cancer screening into a medical school curriculum. Time spent training SPs to play the role of adults with limited literacy was very important, as was time spent pre-testing the cases. The PBL case effectively promoted group discussion of cancer screening and literacy. CONCLUSION: The project succeeded in making students aware of literacy and cancer screening issues. Outcome results are being analyzed.

What did we learn about early clinical experience?

This article explores the lessons learned by ten demonstration schools regarding the early clinical experience (ECE) component of the Interdisciplinary Generalist Curriculum (IGC) PROJECT: Students in ECE at these schools participated in longitudinal, one-to-one or two-on-one preceptorships with primary care physician preceptors in outpatient settings. Development of an ECE was a key component of curricular change at each of the IGC Project schools. Shattering the traditional barrier between preclinical and clinical years of the 2 + 2 medical curriculum model helped create a leading edge for innovation at each of the schools. In this article, the authors incorporated evaluation information from several sources, including the external evaluation reports of the IGC Project, final annual reports from demonstration schools, and curriculum evaluations from the coauthors' schools (the University of Colorado School of Medicine, Nova Southeastern University College of Osteopathic Medicine, and the University of California, San Francisco School of Medicine).

What did we learn about the impact on students' clinical education?

Analysis of the impact of the Interdisciplinary Generalist Curriculum (IGC) Project would be incomplete without discussion of how it affected students' clinical education. This article explores the impact of the IGC Project on medical students' clinical education at the ten IGC schools. The schools typically lacked pre-IGC Project baseline data for comparison, although they all collected data on the impact of the new curriculum on the clinical education of students. Measures included some objective indicators and various subjective measures of the perceptions of the students, faculty, and community preceptors. The impact of curricular innovations at the IGC Project schools on students was immediate as they began to see patients early and continuously as part of their medical education. Students, faculty, and community preceptors who interacted with these students during their third year believed they were "different" because of their participation in the IGC. Not only did the IGC students approach patients with better integrated basic science knowledge, but also a different kind of student arrived at the third year, the traditional beginning of clinical experiences in medical education.

What did we learn about leadership in medical education? Effecting institutional change through the Interdisciplinary Generalist Curriculum Project.

The Interdisciplinary Generalist Curriculum (IGC) Project required significant collaboration and cooperation at many levels of leadership to accommodate early clinical experiences in the curriculum. Three elements of institutional change are discussed: the context for desired early clinical experiences in medical education, structural elements required of the IGC Project schools, and leadership within the demonstration schools. Lessons learned from these interdisciplinary projects include the importance of supportive leadership from the top levels, establishing broad buy-in across sectors of the school, creating a team administrative structure that fosters participation by all groups, and central (rather than departmental) administration. The processes needed to establish collaborative leadership and full participation by the generalist departments and cooperation of diverse constituencies, such as basic science faculty, were labor-intensive and required more time to ensure successful program implementation. Uniformly, strong support at the highest levels of the organization, especially the medical schools' deans, was cited as a key element in the success of the IGC Project. An interesting unanticipated outcome of the project was the movement of the interdisciplinary course administration into a central location (dean's office) by the end of the project for all schools. This change may reflect a practical advantage for administration of interdisciplinary programs located at the level of the school or college, rather than housed within departments.

The Interdisciplinary Generalist Curriculum Project at the University of Colorado School of Medicine.

The University of Colorado School of Medicine first considered a longitudinal primary care preceptorship in 1992, when the dean formed the dean's Ad Hoc Committee to launch the "generalist initiative," to include a three-year required longitudinal generalist preceptorship. Being awarded an Interdisciplinary Generalist Curriculum (IGC) Project contract provided the dean's Ad Hoc Committee with the momentum it needed to enact the curriculum. This article describes the IGC Project at the University of Colorado as it was originally proposed and the intended and unintended outcomes over time. Intended outcomes included establishing early continuous clinical experiences as a vital part of the curriculum and increased exposure to primary care, while examples of unintended outcomes were the development of a longitudinal skill and behavior evaluation process and the integration of problem-based learning in the curriculum. The article concludes with a description of what is ahead for the curriculum.

Student perspectives on primary care preceptorships: enhancing the medical student preceptorship learning environment.

BACKGROUND: Medical students participate in a longitudinal (3-year) primary care preceptorship to assist them in developing skills in interviewing and examining patients in an ambulatory care setting. PURPOSE: To identify from a student's perspective important context and process issues in a longitudinal preceptorship. METHODS: The investigators used an "editing" style of analysis to identify significant themes across 24 medical student focus groups held between October 1995 and December 1997. RESULTS: Significant themes emerged from the data analysis that describe important features of what makes the preceptorship work for students. The main themes are active teaching, active learning, a trusting relationship, sufficient time, and a shared understanding of preceptorship objectives. The potential benefits to students in an enhanced learning environment are comfort, confidence, responsibility, skills, knowledge, reinforcement, learning opportunities, teaching opportunities, and models for practice. CONCLUSIONS: We offer recommendations for enhancing longitudinal preceptorships for preceptors, students, and leaders in medical education.

Characteristics of and issues faced by rural female family physicians.

The purpose of this study was to identify characteristics of and issues faced by female family physicians practicing in rural areas. A 37-item survey was designed to obtain demographic information about the background, community and practice of rural female physicians. An open-ended question regarding the issues and problems faced by female physicians in rural communities was included. Study subjects were identified from the membership of the American Academy of Family Physicians (AAFP). The questionnaire was mailed to all 850 active female AAFP members practicing in communities with less than 50,000 inhabitants during the winter of 1999. Completed and usable surveys were received from 587 (69.9 percent). The average age of respondents was 45. The majority were married (81.1 percent) and had children (80.1 percent). Half of the women had grown up in communities of 25,000 or less population. Twenty-seven percent of the respondents had no rural exposure in medical school; 39 percent had no rural exposure in residency; and 16 percent had no rural exposure in medical school or residency. The majority of respondents (62 percent) practiced in communities of less than 10,000. A large majority (70 percent) of these women planned to stay in the community for 10 years or more, with 58.6 percent responding that they plan to stay indefinitely. Assumptions regarding rural physicians, especially women, must be updated to accurately assist communities in recruiting rural physicians and to assist medical schools and residencies in adequately preparing graduates for rural practice.

Effect of a longitudinal course on student performance in clerkships.

OBJECTIVE: To determine the effect that a 3-year primary-care course experience with family medicine, internal medicine, or pediatric preceptors would have on clerkship performance in pediatrics and internal medicine. DESIGN: In 1 academic year, third-year students were divided retrospectively into 3 groups based on preceptor type in the primary care course. An analysis of variance was conducted. When the analysis of variance showed statistical significance, a multiple-comparison t test was performed. SETTING: University medical school with a longitudinal preceptor experience. PARTICIPANTS: One hundred nine third-year medical students who participated in the primary care course and completed the pediatric and internal medicine clerkships. Fifty-six students took part in the self-assessment portion of the study. MAIN OUTCOME MEASURES: Student performance scores in the pediatric clerkship and internal medicine clerkship were analyzed for significant differences based on preceptor type. Student self-assessment on pediatric objectives was analyzed for significant differences based on preceptor experience. RESULTS: Students with pediatric preceptors received higher clinical scores in the pediatric clerkship (P = .04) and perceived themselves as more advanced on 18 of the 39 pediatric curriculum pretest self-assessment items. Students with pediatric or internal medicine preceptors received significantly higher scores on the written patient medical history and physical examinations (P = .02). There were no significant differences on the pediatric written examination. There were no significant performance differences in the internal medicine clerkship. All hypothesis testing was conducted at the 95% confidence level. CONCLUSION: Experiences with pediatric preceptors in the early years of medical school may improve a student's performance and confidence in the pediatric clerkship.

The family physician and house calls. A survey of Colorado family physicians.

BACKGROUND: Visiting patients at home has long been one of the activities of the family physician, but the practice of making house calls has diminished significantly during the second half of the 20th century. The goal of this study was to describe physicians' attitudes about house calls and their practice of making them in the rapidly changing health care environment of the United States. METHODS: A 30-item, self-administered questionnaire was designed to obtain demographic information about physicians and their attitudes toward house calls, practice experiences with making house calls, and any additional factors that influence making house calls. It was mailed to all members of the Colorado Academy of Family Physicians, during the summer of 1997. RESULTS: A 66% response rate was obtained from practicing physicians. Overall attitudes toward house calls were positive. Fifty-three percent of the respondents reported making house calls, and 8% reported making more than 2 house calls per month. Male physicians, those older than 40 years, those in rural settings, and those trained in a community-based residency were more likely to make house calls. Patient payer mix and practice setting were also related to whether a physician made house calls. House calls were most frequently made to geriatric patients, cancer patients, trauma patients, and patients with transportation difficulties. Many physicians reported using home health agencies for assessment and treatment of patients needing home care. CONCLUSIONS: Family physicians agree that house calls are good for patients. More than half of the respondents reported that they occasionally make house calls. However, few physicians routinely perform house calls.

Update on early medical and surgical abortion.

Abortion is one of the most common surgical procedures in the United States. Recent innovations in medicine make early pregnancy termination safe and effective. Our purpose is to review advances in early detection and confirmation of intrauterine pregnancy and discuss medical and surgical techniques for elective termination early in pregnancy. Manual vacuum aspiration is a safe and effective method for pregnancy termination through 10 weeks' gestation. Medical abortion using methotrexate or mifepristone with misoprostol is safe and effective for early pregnancy termination through 7 weeks' gestation.

Promoting medical student involvement in primary care research.

BACKGROUND AND OBJECTIVES: As the growth of primary care continues, the need for strengthening the scientific foundations of practice becomes more pressing. Although there is general agreement on the importance of promoting primary care research by medical students, little has been reported on how this can be accomplished. The goal of the program described is to involve medical students in primary care research. METHODS: Over the last 7 years, the Department of Family Medicine at the University of Colorado has promoted the involvement of medical students in primary care research through a program consisting of five elements: 1) a student development program (the Family Medicine Scholars Program), 2) financial support for student research, 3) a core of faculty mentors, 4) a strong coordinating effort by the predoctoral education office, and 5) research agendas geared to student schedules. RESULTS: The number of students involved in primary care research, presentations, and publication of papers by students has increased since we initiated our medical student research program 7 years ago. CONCLUSIONS: The elements discussed have proven successful at increasing student participation in primary care research.

How representative of typical practice are practice-based research networks? A report from the Ambulatory Sentinel Practice Network Inc (ASPN)

OBJECTIVE: To evaluate the patients and practices of family physicians in a national practice-based research network to understand whether results from practice-based research networks are likely to be relevant to other practicing clinicians. STUDY DESIGN: Survey focused on family physicians that replicated the National Ambulatory Medical Care Survey (NAMCS). SETTING: The Ambulatory Sentinel Practice Network Inc (ASPN), a practice-based research network, consisting of volunteer primary care practices that serve approximately 350,000 patients. OUTCOME MEASURES: Comparison of visits reported in ASPN with the visits reported in the 1990 NAMCS in terms of patient demographics, reasons for visit, diagnostic and therapeutic services, diagnoses, disposition, and amount of time spent with patients. RESULTS: Overall, the two samples differed with respect to demographic characteristics of patients, while problems, diagnoses, services, disposition, and time spent with patients were similar. Specific pair-wise comparisons identified areas of difference. CONCLUSION: The ASPN and possibly other similar practice-based research networks are sufficiently representative of family practice to serve as useful laboratories in which family practice and primary care can be explored.