End-of-life and palliative care curricula in internal medicine clerkships: a report on the presence, value, and design of curricula as rated by clerkship directors.

PURPOSE: End-of-life and palliative care (EOL/PC) education is a necessary component of undergraduate medical education. The extent of EOL/PC education in internal medicine (IM) clerkships is unknown. The purpose of this national study was to investigate the presence of formal EOL/PC curricula within IM clerkships; the value placed by IM clerkship directors on this type of curricula; curricular design and implementation strategies; and related barriers and resources. METHOD: The Clerkship Directors in Internal Medicine conducted its annual survey of its institutional members in April 2012. The authors analyzed responses to survey items pertaining to formal EOL/PC curriculum and content using descriptive statistics. The authors used qualitative techniques to analyze free-text responses. RESULTS: The response rate was 77.0% (94/122). Of those responding, 75.8% (69/91) believed such training should occur in the IM clerkship, and 43.6% (41/94) reported formal curricula in EOL/PC. Multiple instructional modalities were used to deliver this content, with the majority of programs dedicating four or more hours to the curriculum. Curricula covered a wide range of topics, and student assessment tools were varied. Most felt that students valued this education. The qualitative analysis revealed differences in the values clerkship directors placed on teaching EOL/PC within the IM clerkship. CONCLUSIONS: Although many IM clerkship directors have implemented formal curricula in EOL/PC, a substantial gap remains between those who have implemented and those who believe it belongs in the clerkship. Time, faculty, cost, and competing demands are the main barriers to implementation.

A complementary and alternative medicine workshop using standardized patients improves knowledge and clinical skills of medical students.

OBJECTIVES: As the use of complementary and alternative medicine (CAM) has increased in the general population, so has the interest in CAM education among medical students and medical educators. The purpose of this study is to determine the impact of a CAM workshop using standardized patients (SP) on knowledge and clinical skills of third-year medical students. DESIGN: A 4-hour CAM workshop was developed as part of a new curriculum for a required third-year 4-week primary care internal medicine clerkship. The CAM workshop and 3 other novel workshops were randomized for delivery to half of the rotational groups. The CAM workshop incorporates 4 SP cases representing different clinical challenges. All students in every rotation group are assigned CAM readings. At the end of the rotation, all students take a 100-item written exam (7 CAM items) and 9-station SP exam (1 CAM station) including a post-SP encounter open-ended written exercise. Scores on the written exam CAM items, CAM SP checklist, and CAM open-ended written exercise of workshop participants and nonparticipants were analyzed with simple means, standard deviations, and multiple regression approaches. RESULTS: The CAM workshop was delivered to 12 of the 24 rotation groups during the 2004-2005 and 2005-2006 academic years. Ninety-two students participated in the workshop, and 94 did not. Workshop participants performed significantly better than nonparticipants on the CAM-specific SP checklist items (58 vs 36.6%, P<.0001), post-SP encounter written exercise (76.9 vs 63.3%, P<.0001), and 7 CAM written exam items (84.8 vs 76.3%, P<.0001). CONCLUSIONS: Students participating in a 4-hour SP workshop exhibit superior CAM knowledge as assessed by SP checklist, open-ended exercises, and multiple choice items. It appears that practice with SPs assists in acqusition and application of CAM knowledge and deferential counseling skills.

Enhancing knowledge and clinical skills through an adolescent medicine workshop.

OBJECTIVE: To determine the effect of a medical school adolescent medicine workshop on knowledge and clinical skills using standardized patients. DESIGN: Randomized controlled trial. SETTING: The University of Kentucky College of Medicine, Lexington. PARTICIPANTS: A total of 186 third-year medical students. Intervention Medical students assigned to the intervention group (n = 95) participated in a 4-hour adolescent medicine workshop using standardized patients to practice interviewing and counseling skills. Medical students assigned to the control group (n = 91) participated in an alternative workshop. OUTCOME MEASURES: Medical student adolescent interviewing and counseling skills were assessed using adolescent standardized patient encounters during the end-of-clerkship examination and during the end of the third-year Clinical Performance Examination. Medical student knowledge was assessed at the end of the clerkship using an open-ended postencounter written exercise and the questions specific to adolescent medicine on the clerkship written examination. RESULTS: Both groups had comparable baseline characteristics. Medical students in the intervention group scored significantly higher on both measures of clinical skills, the standardized patient stations during the end-of-clerkship examination and the Clinical Performance Examination. Intervention medical students also scored significantly higher on both measures of knowledge, the open-ended postencounter written exercise and the written examination. CONCLUSIONS: A brief adolescent medicine workshop using standardized patients improved medical students' knowledge and skills at the end of a 4-week clerkship, and the improvement in clinical skills persisted at the end of the third year of medical school.

A needs assessment of complementary and alternative medicine education at the University of Kentucky College of Medicine.

INTRODUCTION: Complementary and alternative medicine (CAM) encompasses a wide variety of increasingly popular therapies not generally taught in allopathic medical schools but of apparent interest to medical trainees. However, little is known about the learners' specific needs for improving their CAM clinical skills. METHODS: Third-year medical students and internal medicine resident-physicians at the University of Kentucky were invited to participate in a voluntary questionnaire to assess CAM knowledge, skills, attitudes as well as their desired learning methods. RESULTS: Medical students (n = 22) and resident-physicians (n = 39) generally hold favorable attitudes toward CAM but admit to significant knowledge deficits and do not feel adept at counseling their patients about CAM. Students indicate observation and hands-on experiences as their preferred pedagogy while residents favor textbooks, articles, and lectures to learn about CAM. Nevertheless, one resident noted, "any information in any format would be helpful as we get no teaching in this area". CONCLUSIONS: In our sample, learner-driven CAM education at undergraduate and graduate levels is indeed necessary and wanted. In constructing CAM education interventions, attitudes, perceived knowledge deficits, and preferred learning strategies should be considered for the trainees and thus ultimately responsive to the needs of their patients.

Sexual history inquiry and HIV counseling: improving clinical skills and medical knowledge through an interactive workshop utilizing standardized patients.

BACKGROUND: Sexual history and HIV counseling (SHHIVC) are essential clinical skills. Our project's purpose was to evaluate a standardized patient educational intervention teaching third-year medical students SHHIVC. METHODS: A four-hour standardized patient workshop was delivered to one-half of the class each of three consecutive years at one medical school. Approximately 3.5 weeks later, all students engaged in a standardized patient examination including one station assessing SHHIVC, answered an open-ended written exercise following the standardized patient encounter, and completed a written examination including sexual history and HIV-related questions. RESULTS: Workshop participants scored higher than non-participants on SHHIVC items on the standardized patient station (P < .0001), written exam (P < .0001), and open-ended written exercise after the standardized patient encounter (P = .024). CONCLUSIONS: Our SHHIVC curriculum was associated with students demonstrating better clinical skills on a SHHIVC standardized patient examination station and more SHHIVC knowledge on two measures of medical knowledge than students not participating in the SHHIVC educational intervention.

Student involvement on teaching rounds.

BACKGROUND: Inpatient internal medicine education occurs in a fragile learning environment. The authors hypothesized that when medical students are involved in teaching rounds, residents may perceive a decrease in value of attending teaching. METHOD: During two summer periods, trained research assistants shadowed teaching rounds, tracking patient census and team call status, recording basic content of rounds, and delivering a survey instrument to the learners, asking them to rate the quality of the attending's teaching that day. RESULTS: One hundred sixty-six rounds were analyzed. Attending teaching ratings peaked when students were highly involved. In fact, high student involvement was an independent predictor of higher resident evaluation of teaching rounds (P < .0001). CONCLUSIONS: The best teaching occurred when involvement of medical students was greatest and their involvement was not necessarily a zero-sum game. The authors conclude that attending investment in medical student education during teaching rounds benefits all members of the inpatient team.

Do pressure and fatigue influence resident job performance?

BACKGROUND: Global surveys of residents have consistently identified stress variables as important factors in resident job performance. AIMS: Determine whether an association exists between resident stress and job performance. METHOD: Over a three month period, interns on our inpatient ward services were surveyed regarding their current call schedule, whether their prior night's sleep was sufficient, whether they felt pressed by other commitments, whether they spent enough time teaching medical students and whether they had completed all patient care issues on a given day. Multiple logistic regression was used to assess the association between call status, pressure and sleep adequacy with reported omissions in patient care and adequacy of teaching. RESULTS: In the regression analysis, ratings of high pressure and insufficient sleep but not call status independently predicted outcomes. For example, if an intern felt both pressed and tired, they were over eight times more likely to omit a patient care issue and over four times more likely to report inadequate teaching. CONCLUSIONS: Subjective ratings of high pressure and insufficient sleep are associated with poor job performance in medical residents.

Are continuity clinic patients less satisfied when residents have a heavy inpatient workload?

The purpose of this study was to assess the influence of resident non-clinic workload on the satisfaction of continuity clinic patients. Over a 2-month period in 2002, residents and patients were surveyed at the University of Kentucky internal medicine continuity clinic. Residents provided a self-report of their non-clinic workload as light or medium versus heavy or extremely heavy. Patient satisfaction was assessed with a 7-item, 10-point scale with items derived from commonly used patient satisfaction instruments. In 168 patient encounters, patients were significantly less satisfied with their clinic visit if they were seen by a resident who had a heavier workload. In addition, these patients gave significantly lower ratings with regard to the amount of time spent with the patient during the visit, and how well the resident listened and paid attention. Although alternative explanations exist, we propose that heavy hospital workload is associated with decreased patient satisfaction in resident continuity clinic.

Can physicians improve patient satisfaction with long waiting times?

The purpose of our study was to determine how time spent with the physician might be related to patient dissatisfaction with their waiting time. During a 2-month period, patients in our internal medicine resident continuity clinic completed a survey assessing their satisfaction with their waiting time and their estimates of their waiting time and time spent with the resident physician. For patients with long waiting times (more than 15 min in the waiting room or more than 10 min in the exam room), patient dissatisfaction with waiting time was associated with a shorter physician visit (48% were dissatisfied if the physician spent less than 15 min vs. 18% if the physician spent more than 15 min with them, p = .03). These data suggest that physicians can mediate the negative effects of long waiting times by spending more time with their patients. Future studies on patient satisfaction should consider this interaction.

Improving students' sexual history inquiry and HIV counseling with an interactive workshop using standardized patients.

Sexual history and HIV counseling are essential clinical skills. Our project's purpose was to evaluate a standardized patient (SP) educational intervention teaching third-year medical students sexual history taking and HIV counseling. A 4-hour SP workshop was delivered to one-half of the class. Four weeks later, all students engaged in an SP examination including one station on assessing sexual history taking and HIV counseling. Workshop participants scored one standard deviation higher on sexual history and HIV counseling items than nonparticipants. Our sexual history and HIV counseling curriculum was associated with students asking more thorough sexual histories and providing more HIV counseling.

Are continuity clinic patients less satisfied when the resident is postcall?

Due to recent public debate and newly imposed resident work hour restrictions, we decided to investigate the relationship of resident call status to their ambulatory patients' satisfaction. Resident continuity clinic patients were asked to rate their level of satisfaction on a 10-point Likert-type scale. Using multiple regression approaches, these data were then assessed as a function of resident call status. We found that in 646 patient encounters, patient satisfaction scores were significantly less when the resident was postcall, 8.99 +/- 1.8, than when not postcall, 9.31 +/- 1.3. We herein discuss etiologies and implications of these findings for both patient care and medical education.