A clinical performance exercise for medicine--pediatrics residents emphasizing complex psychosocial skills.

PURPOSE: To assess the skills of internal medicine-pediatrics (med-peds) residents in evaluating and counseling patients with complex psychosocial problems using a clinical performance exercise (CPE). METHOD: The authors designed a 13-station CPE [nine standardized-patient (SP) stations and four non-SP stations]. Eight of the SP stations focused on counseling or assessing complex psychosocial needs, and three were videotaped and analyzed for specific verbal and nonverbal communication skills. Residents completed a written task for each station and SPs completed a checklist on interviewing and communication skills and a 52-item patient's-satisfaction survey. All first- and third-year residents (n = 25) from two academic years participated. RESULTS: The range of the average scores on the nine SP stations was 43-75%. The residents performed better with common problems (newborn hospital discharge instructions and cardiac risk-factor counseling) than with more complex problems that are less often encountered in the institution (HIV counseling), or problems less often recognized (adult survivor of childhood sexual abuse). As expected, third-year residents scored better than did first-year residents on the written "plan" part of the SP stations and on the non-SP stations. Third-year and first-year residents had similar scores, however, on measures of verbal and nonverbal communication and patient's satisfaction, and for gathering data and providing information. CONCLUSION: This is the first performance-based evaluation of residents in a combined med-peds residency program. The stations addressed more complex clinical skills than those reported for objective structured clinical evaluations of residents.

A pilot study assessing the influences of charge data and group process on diagnostic test ordering by residents.

PURPOSE: Providing charge data to resident physicians has been shown to reduce the amounts spent on diagnostic testing. This pilot study sought to determine the influences of charge data and group decision making on diagnostic test ordering by internal medicine residents. METHOD: In an interactive workshop, 23 internal medicine residents received a hypothetical case. They completed an 18-item questionnaire estimating charges for diagnostic tests and then "ordered" tests. The residents were then randomly divided into groups that either received charge data, received charge data after ordering tests, or received no charge data. The groups ordered tests by consensus. Tests were weighted for appropriateness (+1 to +6) and inappropriateness (-1 to -6). Analyses compared individual and group decisions and effect of availability of charge data. RESULTS: Residents with access to charge data spent less on tests, but also had lower appropriateness scores. The appropriateness of the diagnostic workup was better by groups than by individuals, but cost more. CONCLUSION: Cost-containment interventions targeted towards doctors in training need to address the effect on quality of care and the influence of the group process in clinical decision making. Group diagnostic decisions may be more costly, but more appropriate.

The loss of student idealism in the 3rd-year clinical clerkships.

The purpose of this study was to specify how student attitudes toward different types of patients and the profession change during clinical rotations. A questionnaire was given to all medical students prior to 3rd-year rotations regarding their attitudes toward the medical profession and patient types. It was given again after students completed their 16-week medicine-surgery clerkship. Eighty-eight of 96 students responded to pre- and posttests. Students became less idealistic toward two patient groups: the elderly and people with chronic pain. After clerkship, students believed a greater percentage of the elderly were demented (26% increasing to 35%, p = .09 and that a greater percentage of patients with chronic pain are drug seekers (15% increasing to 24%, p = .004). The authors conclude that in the 3rd year of medical school students become less idealistic toward elderly patients, those with chronic pain, and the profession.

Self- and peer assessment in a first-year communication and interviewing course.

Peer and self-evaluation are crucial in the professional development of physicians. However, these skills must be learned, and there are barriers to their acceptance and successful utilization. To overcome these obstacles, it has been suggested that these concepts should be addressed longitudinally throughout medical education. Therefore, first-year medical students were introduced to peer and self-assessment as part of a videotape review during an interviewing course by having students complete written peer and self-assessments of the interviews. Students' self-assessments were compared with the assessments of peers and faculty. Written evaluations showed peers were more lenient than faculty and students were most critical of their own performances. Students could provide balanced assessments of their peers but were predominately negative regarding their own performances. It appears first-year students are capable of evaluating their peers but have difficulty accurately assessing their own performance. Further interventions are needed to foster self-assessment skills in first-year students.

Specialty choices of students who actually have choices: the influence of excellent clinical teachers.

PURPOSE: To determine the influence of the quality of attending physicians and residents on the specialty choices of excellent medical students, who actually have a broad choice of specialties. METHOD: In 1993-94 and 1994-95, 169 third-year students at the University of Kentucky College of Medicine were randomly assigned to two one-month rotations on general medicine inpatient wards. At the end of each rotation, the students confidentially evaluated the attending physician and the supervising resident (different for each rotation) with whom they had worked. Data were collected for 62 attending physicians and 89 residents. The authors analyzed the influences of the "best" and "worst" clinical instructors (those rated in the top and the bottom 20% by all students with whom they had worked over the two years) on "excellent" medical students (the 52 students whose USMLE I scores were in the top 30% of their class). RESULTS: Using regression approaches from the general linear model, the authors found that independent predictors of internal medicine residency choice for excellent medical students were exposure to highly rated internal medicine attendings (p = .02) and residents (p = .03). Nine of 29 (30%) of the excellent students who worked with a "best" medicine clinical instructor chose an internal medicine residency, while none of the 23 excellent medical students who did not work with a "best" medicine clinical instructor did so. The authors found no correlation in students' ratings of their pairs of attendings and residents, suggesting that rater bias did not explain the results. CONCLUSION: Better medical students who work with the best internal medicine attending physicians and residents in their internal medicine clerkship are more likely to choose an internal medicine residency.

Patient satisfaction with care in programs for low income individuals.

Although a variety of public and private programs provide care for low-income individuals, little is known about patient satisfaction across these programs. The objective of this study was to examine patient satisfaction across a variety of health insurance programs. A survey was conducted of randomly selected adults in Kentucky who had an outpatient visit in the past 12 months (616 with private insurance, 683 Medicaid recipients, 287 in private sector charity program for uninsured indigents). Patient satisfaction with multiple dimensions of their most recent outpatient visit was assessed. All insurance groups were generally satisfied with the care received in their most recent visit. For all 8 dimensions of patient satisfaction, the private insurance group was significantly higher than the other groups. In a model controlling for standard demographic and health status variables, higher overall satisfaction with the visit was positively related to higher income and higher mental health functional status. The insurance category variable had no significant relationship to overall satisfaction with the visit. Although patients receiving care through health insurance programs for low-income individuals are generally satisfied with the services, there is an indication that low-income individuals, regardless of insurance type, are less satisfied with the care they receive.

Access to care for the uninsured: is access to a physician enough?

OBJECTIVES: This study examined a private-sector, statewide program (Kentucky Physicians Care) of care for uninsured indigent persons regarding provision of preventive services. METHODS: A survey was conducted of a stratified random sample of 2509 Kentucky adults (811 with private insurance, 849 Medicaid recipients, 849 Kentucky Physicians Care recipients). RESULTS: The Kentucky Physicians Care group had significantly lower rates of receipt of preventive services. Of the individuals in this group, 52% cited cost as the primary reason for not receiving mammography, and 38% had not filled prescribed medicines in the previous year. CONCLUSIONS: Providing free access to physicians fills important needs but is not sufficient for many uninsured patients to receive necessary preventive services.

Housestaff workload and procedure frequency in the neonatal intensive care unit.

OBJECTIVE: To investigate the association of clinical workload and the decision to perform procedures on infants in the neonatal intensive care unit (NICU). DESIGN: Prospective cohort study over one academic year, observing infants exposed to housestaff working under various levels of clinical workload. SUBJECTS: All 31 housestaff rotating on the NICU service during the academic year 1993 to 1994 were observed. A total of 785 infants were admitted to these housestaff. SETTING: One academic Level III intensive care nursery. MEASUREMENTS AND MAIN RESULTS: Clinical workload was operationalized as number of NICU infants cared for by the individual houseofficer on-call each night. The procedures of interest were number of umbilical artery catheters (UACs), intubations, lumbar punctures (LPs), and peripheral phlebotomy performed by the houseofficer on-call. Using multiple linear regression approaches, controlling for the average severity-of-illness of each of the NICU infants, the experience and residency program of the houseofficer on-call, and the individual attending, we found that increased clinical workload (number of NICU infants) resulted in a significantly greater probability that an admitted infant received an umbilical artery catheter (p = .02), but resulted in less probability that any NICU infant received a lumbar puncture (p = .0001) or peripheral phlebotomy (p = .0002). The decision to intubate an infant was not affected by the workload in the NICU. CONCLUSIONS: The clinical workload of housestaff in the NICU can affect decisions to perform procedures on infants in the NICU. For equivalently severely ill infants, there is a greater chance of receiving a UAC and less chance of being phlebotomized or receiving an LP when workload is high. Attending neonatologists need to be sensitive to possible effects of workload on patient care in the NICU.

Surgical teaching quality makes a difference.

BACKGROUND: This study examined the influence of the quality of faculty members' teaching on student performance in a third-year surgery clerkship. METHODS: Eighty-nine third-year students on a surgery clerkship completed preceptor evaluation forms. The faculty member's overall score was the mean of ratings from all the third-year students for whom that faculty member served as preceptor during the year. We examined associations between these ratings and student performance on the National Board of Medical Examiners (NBME) surgery subject examination and clerkship Objective Structured Clinical Examination (OSCE) by using an analysis of covariance that controlled for prior academic achievement [United States Medical Licensure Examination (USMLE) Part I]. RESULTS: The average mean teaching evaluation score was associated with the scores on the NBME surgery subject examination (P = 0.0005). Students with attendings who received poor teaching evaluations performed more poorly on OSCE data-gathering stations than did students with attendings rated as average or good. CONCLUSIONS: The study results indicate that the teaching quality of surgery faculty appears to have an impact on student performance.

Evaluation of students' learning in an interdisciplinary medicine--surgery clerkship.

PURPOSE: To evaluate the impact of an interdisciplinary medicine-surgery clerkship (created to foster generalist education) on students' performances on National Board of Medical Examiners' (NBME) subject examinations. METHOD: Test data for the 226 students who participated in the 16-week combined clerkship and for the 265 students who had completed the traditional clerkships (12 weeks of medicine, 12 weeks of surgery) were compiled and analyzed using t-tests for independent samples. RESULTS: Mean scores on the NBME subject examination in medicine increased significantly after the combined medicine-surgery clerkship (from 433 to 455, p < or = 0.5). Mean scores on the NBME subject examination in surgery were similar to those achieved in the traditional clerkship years. CONCLUSION: Since the medicine and surgery clerkships were combined into a single, interdisciplinary clerkship, students' scores have increased on the medicine NBME subject examination and have remained relatively unchanged on the surgery NBME subject examination, despite a substantial reduction in students' clinical experience in the combined clerkship from the traditional clerkships (16 vs 24 weeks).

The effect at one teaching hospital of interns' workloads on the satisfaction of their patients.

PURPOSE: To explore whether the amount of workload of first-year residents (interns) affects the satisfaction of their patients. METHOD: The authors collected data from January through May 1995 for 145 patients admitted to Lexinton Veterans Affairs Medical Center with the primary diagnosis of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). Workload was measured as the number of other patients for whom the intern had primary responsibility on the day of the studied patient's admission. A questionnaire measured the patients' satisfaction on the day of discharge. The authors analyzed the data using Pearson correlation and multiple linear regression. RESULTS: For the 89 patients with COPD (controlling for patient age, severity of illness, and sex of intern), greater workloads for their interns was a significant predictor of decreased patients' satisfaction (p = .001). No association was found for the 56 patients with CHF. CONCLUSION: Interns' workloads on the day their patients are admitted can influence their patients' subsequent satisfaction.

House staff supervision, workload, and experience in the neonatal intensive care unit: results of a national survey.

One hundred fifty-nine pediatric chief residents were surveyed regarding characteristics of the neonatal intensive care unit rotation for house staff at their institution. We documented substantial interinstitution variability in house staff NICU rotations in terms of number of rotations, and the workload and supervision of house staff.

A randomized trial of providing house staff with patient social history information. Effect on patient outcomes.

The purpose of this project was to assess if providing physicians (house staff) with routine comprehensive social history information on their patients will improve patient outcomes. Comprehensive social history information was gathered over a 5-month period on 134 consecutive patients. Patients were randomized to have social history information provided or not provided to the resident physician caring for them. Outcomes of interest were: patient satisfaction, length of stay, and early unplanned readmission. Analysis was with analysis of covariance, controlling for patient severity of illness and amount of social history information documented by the house officer. Outcomes were the same for patients for whom house staff were provided social history information versus those for whom the information was not provided. The authors conclude that providing house staff with routine comprehensive social history information did not influence patient outcomes.