Development and pilot testing of an online case-based approach to shared decision making skills training for clinicians.

BACKGROUND: Although research suggests that patients prefer a shared decision making (SDM) experience when making healthcare decisions, clinicians do not routinely implement SDM into their practice and training programs are needed. Using a novel case-based strategy, we developed and pilot tested an online educational program to promote shared decision making (SDM) by primary care clinicians. METHODS: A three-phased approach was used: 1) development of a conceptual model of the SDM process; 2) development of an online teaching case utilizing the Design A Case (DAC) authoring template, a well-tested process used to create peer-reviewed web-based clinical cases across all levels of healthcare training; and 3) pilot testing of the case. Participants were clinician members affiliated with several primary care research networks across the United States who answered an invitation email. The case used prostate cancer screening as the clinical context and was delivered online. Post-intervention ratings of clinicians' general knowledge of SDM, knowledge of specific SDM steps, confidence in and intention to perform SDM steps were also collected online. RESULTS: Seventy-nine clinicians initially volunteered to participate in the study, of which 49 completed the case and provided evaluations. Forty-three clinicians (87.8%) reported the case met all the learning objectives, and 47 (95.9%) indicated the case was relevant for other equipoise decisions. Thirty-one clinicians (63.3%) accessed supplementary information via links provided in the case. After viewing the case, knowledge of SDM was high (over 90% correctly identified the steps in a SDM process). Determining a patient's preferred role in making the decision (62.5% very confident) and exploring a patient's values (65.3% very confident) about the decisions were areas where clinician confidence was lowest. More than 70% of the clinicians intended to perform SDM in the future. CONCLUSIONS: A comprehensive model of the SDM process was used to design a case-based approach to teaching SDM skills to primary care clinicians. The case was favorably rated in this pilot study. Clinician skills training for helping patients clarify their values and for assessing patients' desire for involvement in decision making remain significant challenges and should be a focus of future comparative studies.

Integrating telemedicine instruction into the curriculum: expanding student perspectives of the scope of clinical practice.

We have developed a telemedicine elective for fourth-year medical students to learn about the delivery of primary care telemedicine. The goals were to expose medical students to telemedicine as a method for delivery of primary care and to reinforce the importance of doctor-patient communication during the health-care encounter. The elective lasted four weeks. It had three components: two online introductory courses to telemedicine; site visits to near and distant telemedicine sites; and a reflective writing paper. In the first year, seven medical students out of a class of 230 chose the telemedicine elective from a list of 188 alternatives. Evaluation ratings and the students' written comments, along with end-of-course discussions, indicated that the telemedicine elective was a valuable experience. An elective in the medical school curriculum may be a useful way of providing future physicians with an understanding of telemedicine.

Learning outcomes from a biomedical research course for second year osteopathic medical students.

BACKGROUND: A ubiquitous dilemma in medical education continues to be whether and how to integrate research competencies into the predoctoral curriculum. Understanding research concepts is imbedded in the six core competencies for physicians, but predoctoral medical education typically does not explicitly include research education. In an effort to quickly report academic research findings to the field, this is the second in a series of articles reporting the outcomes of a research education initiative at one college of osteopathic medicine. The first article described the competency model and reported baseline performance in applied understanding of targeted research concepts. This second article reports on the learning outcomes from the inaugural year of a course in basic biomedical research concepts. METHODS: This course consisted of 24 total hours of classroom lectures augmented with web-based materials using Blackboard Vista, faculty moderated student presentations of research articles, and quizzes. To measure changes in applied understanding of targeted research concepts in the inaugural year of the course, we administered a pretest and a posttest to second year students who took the course and to first year students who took an informatics course in the same academic year. RESULTS: We analyzed 154 matched pretests and posttests representing 56% of the 273 first and second year students. On average, the first year (53) and second year students (101) did not differ in their mean pretest scores. At posttest the second year students showed significant improvement in their applied understanding of the concepts, whereas the first year students' mean posttest score was lower than their mean pretest score. CONCLUSIONS: This biomedical research course appears to have increased the second year students' applied understanding of the targeted biomedical research concepts. This assessment of learning outcomes has facilitated the quality improvement process for the course, and improved our understanding of how to measure the benefits of research education for medical students. Some of the course content and methods, and the outcome measures may need to be approached differently in the future to more effectively lay the foundation for osteopathic medical students to utilize these concepts in the clinical setting.

Biomedical research competencies for osteopathic medical students.

BACKGROUND: Without systematic exposure to biomedical research concepts or applications, osteopathic medical students may be generally under-prepared to efficiently consume and effectively apply research and evidence-based medicine information in patient care. The academic literature suggests that although medical residents are increasingly expected to conduct research in their post graduate training specialties, they generally have limited understanding of research concepts.With grant support from the National Center for Complementary and Alternative Medicine, and a grant from the Osteopathic Heritage Foundation, the University of North Texas Health Science Center (UNTHSC) is incorporating research education in the osteopathic medical school curriculum. The first phase of this research education project involved a baseline assessment of students' understanding of targeted research concepts. This paper reports the results of that assessment and discusses implications for research education during medical school. METHODS: Using a novel set of research competencies supported by the literature as needed for understanding research information, we created a questionnaire to measure students' confidence and understanding of selected research concepts. Three matriculating medical school classes completed the on-line questionnaire. Data were analyzed for differences between groups using analysis of variance and t-tests. Correlation coefficients were computed for the confidence and applied understanding measures. We performed a principle component factor analysis of the confidence items, and used multiple regression analyses to explore how confidence might be related to the applied understanding. RESULTS: Of 496 total incoming, first, and second year medical students, 354 (71.4%) completed the questionnaire. Incoming students expressed significantly more confidence than first or second year students (F = 7.198, df = 2, 351, P = 0.001) in their ability to understand the research concepts. Factor analyses of the confidence items yielded conceptually coherent groupings. Regression analysis confirmed a relationship between confidence and applied understanding referred to as knowledge. Confidence scores were important in explaining variability in knowledge scores of the respondents. CONCLUSION: Medical students with limited understanding of research concepts may struggle to understand the medical literature. Assessing medical students' confidence to understand and objectively measured ability to interpret basic research concepts can be used to incorporate competency based research material into the existing curriculum.

Human factors in primary care telemedicine encounters.

Traditional delivery of primary care takes place in a face-to-face transaction between provider and patient. In telemedicine, however, the transaction is 'filtered' by the distance and technology. The potential problem of filtered communication in a telemedicine encounter was examined from a human factors perspective. Patients with and without experience of telemedicine, and providers who had experience of telemedicine, were asked about patient-provider relationships in interviews and focus groups. Seven themes emerged: initial impressions, style of questions, field of view, physical interaction, social talk, control of encounter and ancillary services. This suggests that communication can be improved and better patient-provider relationships can be developed in a primary care telemedicine encounter if attention is paid to four areas of the interaction: verbal, non-verbal, relational and actions/transactional. The human factors dimension of telemedicine is an important element in delivery of health care at a distance - and is one of few factors over which the provider has direct control.

Barriers, strategies, and lessons learned from complementary and alternative medicine curricular initiatives.

Fifteen U.S. academic programs were the recipients of a National Center for Complementary and Alternative Medicine R25 Education Grant Program to introduce curricular changes in complementary and alternative medicine (CAM) in their institutions. The authors describe the lessons learned during the implementation of these CAM education initiatives. Principal investigators identified these lessons along with discovered barriers and strategies, both those traditionally related to medical and nursing education and those unique to CAM education. Many lessons, barriers, and strategies were common across multiple institutions. Most significant among the barriers were issues such as the resistance by faculty; the curriculum being perceived as too full; presenting CAM content in an evidence-based and even-handed way; providing useful, reliable resources; and developing teaching and assessment tools. Strategies included integration into existing curriculum; creating increased visibility of the curriculum; placing efforts into faculty development; cultivating and nurturing leadership at all levels in the organization, including among students, faculty, and administration; providing access to CAM-related databases through libraries; and fostering efforts to maintain sustainability of newly established CAM curricular elements through institutionalization and embedment into overall educational activities. These lessons, along with some detail on barriers and strategies, are reported and summarized here with the goal that they will be of practical use to other institutions embarking on new CAM education initiatives.

"Coming about!"--a faculty workshop on teaching beliefs.

BACKGROUND: The role of faculty in academic health care centers is changing rapidly. Identifying and examining personal teaching beliefs and values can help faculty members improve their performance and change the way in which they view their roles as educators. DESCRIPTION: A structured, 2-h workshop is detailed in this paper. It involves individual reflection, facilitated small group dialogue, and large group discussion. Expected outcomes of the workshop are a start on a teaching philosophy for inclusion in a faculty teaching portfolio, along with a personal metaphor for teaching. EVALUATION: This workshop has been offered nine times with both campus faculty and community preceptors. Both qualitative and quantitative measures are detailed that demonstrate its value. CONCLUSIONS: Faculty members should be provided with structured opportunities to reflect on evolving issues in medical education. This workshop on teaching beliefs is one effective way of challenging faculty to reexamine personal values.

Creating sustainable curricular change: lessons learned from an alternative therapies educational initiative.

The authors describe the process by which a curriculum was developed to introduce complementary and alternative medicine topics at multiple levels from health professional students to faculty, as part of a five-year project, funded by a grant from the National Institutes of Health, at the University of Texas Medical Branch in Galveston, Texas, from 2001 to 2005. The curriculum was based on four educational goals that embrace effective communication with patients, application of sound evidence, creation of patient-centered therapeutic relationships, and development of positive perspectives on wellness. The authors analyze the complex and challenging process of gaining acceptance for the curriculum and implementing it in the context of existing courses and programs. The developmental background and context of this curricular innovation at this institution is described, with reference to parallel activities at other academic health centers participating in the Consortium of Academic Health Centers for Integrative Medicine. The authors hold that successful curricular change in medical schools must follow sound educational development principles. A well-planned process of integration is particularly important when introducing a pioneering curriculum into an academic health center. The process at this institution followed six key principles for successful accomplishment of curriculum change: leadership, cooperative climate, participation by organization members, politics, human resource development, and evaluation. The authors provide details about six analogous elements used to design and sustain the curriculum: collaboration, communication, demonstration, evaluation, evolution, and dissemination.

Lessons learned from complementary and integrative medicine curriculum change in a medical school.

OBJECTIVES: This paper describes a pilot study that examined lessons learned from the introduction of complementary and alternative medicine (CAM) elements into a medical school curriculum. METHODS: A qualitative approach was selected as a first step in evaluating the phenomenological experience of introducing the CAM Educational Project in 2000-05. In 2005, semi-structured interviews were conducted with faculty staff and graduating students who had participated in all 4 years of the CAM Project. Qualitative content was analysed focusing on linguistic data and contextual meaning. RESULTS: The overall response to the integration of CAM curricular elements into the medical school curriculum was positive among all faculty and graduating medical students. Participant experiences were often dependent on the perceived rigour of alternative approaches to a presenting patient problem, along with the importance attributed to openness to patient perspectives as part of evidence-based practices. There was an appreciation of the importance of developing increased awareness and utilisation of CAM in medical practice, as well as a recognition of resistance by some medical school faculty to CAM approaches. CONCLUSIONS: This evaluation of a specific CAM educational project suggests potentially transferable findings to other medical schools. Integrating CAM into the medical school curriculum requires a dedicated team if it is to result in a significant change. This change requires that CAM practices are visible to both students and faculty, that there is a co-operative climate, accessible resources, and institutional support, and that CAM content is embedded into the existing curriculum. All these factors combined can lead to sustainable integration of CAM content issues into the medical school curriculum.

Measuring what medical students think about complementary and alternative medicine (CAM): a pilot study of the complementary and alternative medicine survey.

With increasing national and international support for the development of Complementary and Alternative Medicine (CAM) curricula in American medical schools, it is essential to measure what learners know and believe about CAM in order to assess outcomes of new teaching efforts. This paper describes the development and initial results of a survey designed for those purposes. The survey is constructed so that earlier single-institution studies of students' attitudes toward CAM topics, preferred ways of learning about CAM, and students' use of CAM therapies for self-care might be replicated and extended. A pilot test of the Complementary and Alternative Medicine ( CAM) Survey was conducted with third-year medical students at the University of Texas Medical Branch. Validity and reliability studies of the survey were conducted. Findings were compared to those of previously published studies. Interpretable subscales were constructed from survey questions. Students' attitudes toward CAM-related topics were generally favorable. More students were familiar with biological-based therapies than with other CAM therapies. The majority of respondents listed lectures as their preferred way to learn about CAM. Respondents' own CAM use varied; minority and economically-disadvantaged students were more likely to use CAM therapies than other students. The survey is a promising assessment of student attitudes toward and knowledge of CAM therapies.

Relating student performance on a family medicine clerkship with completion of Web cases.

BACKGROUND AND OBJECTIVES: This study's goal was to determine if completing Web cases improved students' performance on clerkship assessments. METHODS: We compared scores on preceptor evaluations, National Board of Medical Examiners (NBME) Subject Exam, and a standardized patient (SP)-based exam using ANCOVA for students choosing to complete assigned cases versus students not completing the assignment. We controlled for prior academic performance and clerkship timing using US Medical Licensing Exam (USMLE) Step 1 scores and rotation order. RESULTS: Students completing the case assignment scored higher on the NBME subject exam and the SP-based exam. CONCLUSION: Web-based learning was associated with improved student performance on clerkship assessments.

Student perspectives on the integration of interactive Web-based cases into a family medicine clerkship.

BACKGROUND: Web-based methods are increasingly used to educate medical students; several clerkships now use Web-based cases to supplement students' clinical experiences. However, few studies have reported on students' responses to specific features of interactive Web-based cases. DESCRIPTION: We developed an online template to author Web cases and created eight cases. We evaluated the usefulness of case-based learning for students at the end of each clerkship period, using a 9-item questionnaire with a 6-point scale, written student comments on the Web cases, and student focus groups. EVALUATION: We report a 95% response rate, with 85% of students completing all 3 Web cases. Students were most enthusiastic about feedback from faculty after completing each module. They also liked the user-friendly Web design and linear format of the Web cases. CONCLUSION: Students were enthusiastic about the interactive Web-based cases and thought that the cases reinforced knowledge on common medical problems seen in the clinical setting.

Perspectives on the patient-provider relationship in primary-care telemedicine.

This discussion outlines the rationale for considering the importance of the patient-provider relationship in primary care telemedicine. Although connectivity issues and cost effectiveness will continue to be necessary areas of discussion in the delivery of telemedicine, the patient- provider relationship, "filtered" by distance and technology, is equally important. Enhancing patient-provider communication in a telemedicine encounter should be at the center of the next set of research questions, and the focus of this discussion.

Community preceptors' attitudes toward and practices of complementary and alternative medicine: a Texas survey.

To assess attitudes toward and practices of complementary and alternative medicine (CAM) in Texas, a survey was developed and sent to 143 community preceptor physicians in September 2001. The results of the survey represent what the physicians of Texas believe about CAM as a practice and about the relationship of CAM to the medical community. Results indicate that the concept of CAM is relatively well accepted, continuing education is enthusiastically accepted, and support for medical school education is strong; however, physicians also report concerns over the attitudes of their colleagues toward CAM as well as a wide range of concerns about CAM therapy in general. The physicians verify that patients seem to expect them to be knowledgeable about CAM therapies and note some frustrations with the lack of opportunity for fact-based continuing education.

Student Perceptions of the Professional Behavior of Faculty Physicians.

This study was conducted to obtain a baseline understanding of the professional behavior of clinical faculty physicians from the medical students' perspective. Students completed a professionalism evaluation of supervising faculty at the end of each required third-year clerkship over a one year period. Results were analyzed by specific behaviors and across clerkships. Differences were noted in the frequency of the types of problems seen, and varied by clerkship discipline. The most common transgressions of professional behavior reported were the use of derogatory language towards other services or patients and the disrespectful treatment of others. Our study served to provide objective feedback to the faculty about student perceptions of faculty as role models for professionalism while on clinical rotations.

Clinical performance assessment and interactive video teleconferencing: an iterative exploration.

BACKGROUND: The direct observation of students in authentic settings by faculty provides valuable feedback on performance and helps ensure mastery of clinical skills. DESCRIPTION: We explored the use of interactive video technology (IVT) as a way of involving community preceptors as raters on a clinical performance exam for 3rd-year students after their family medicine clerkship. Family medicine preceptors, from locations in their communities, observed students on campus conduct interviews and physical exams of standardized patients and then interacted with them during their case presentations. EVALUATION: We chose an action research approach to this project and conducted four independent trials. Interviews and observations were structured around three areas of concern: human, technical, and institutional. CONCLUSIONS: We feel confident in recommending IVT as a viable option for involving community preceptors in high-stakes testing and with other campus-based activities. We also report on the value of IVT in faculty development activities.

Self-directed learning: looking at outcomes with medical students.

BACKGROUND AND OBJECTIVES: Self-directed learning (SDL) skills are thought to be associated with lifelong learning. This study assessed the degree of readiness for SDL in third-year medical students who participated in a problem-based learning (PBL) curriculum during thefirst 2 years of medical school. METHODS: A total of 182 third-year medical students at the University of Texas Medical Branch at Galveston were given the Self-directed Learning Readiness Scale (SDLRS). RESULTS: The observed mean (235.81 [range 183-284]) for the combined group was significantly higher than the mean reported for general adult learners (214), though slightly lower than scores reported in studies of other medical students and professionals. Ratings of students by clinical preceptors correlated with SDLRS scores. CONCLUSIONS: Students in our integrated medical curriculum had scores on the SDLRS that correlated with clinical performance and probably represented a readiness for SDL.