Predictors of medical students' ethical decision-making: A pilot study using the Theory of Interpersonal Behavior.

OBJECTIVE: To understand medical students' (MS) ethical decision-making using the Theory of Interpersonal Behavior (TIB). METHODS: We conducted two rounds of focus groups to develop a TIB-based questionnaire by eliciting students' perspectives on an ethical dilemma they will encounter in a standardized patient (SP) station, in which an SP "surgeon" asked them to intubate a sedated patient whom the student knew had requested no student involvement. We administrated questionnaires to 241 third-year MS following this SP station, asking for their decisions in the SP station and if a surgeon made the same request in their clerkship. Confirmatory factor analysis (CFA) was used to test whether observed data fit the proposed TIB-based model. RESULTS: The CFA provided an acceptable fit to the a priori proposed model. Fifty-five percent of students indicated they would intubate in an actual situation versus 18% in the SP station (p < 0.05). Using logistic regression, TIB domains affect and facilitating factors reported significant association with students' decisions in both the SP and hypothesized actual situations. CONCLUSIONS: The TIB appears to be an effective theoretical framework for explaining students' ethical decision-making. PRACTICE IMPLICATIONS: The TIB may guide design and assessment of educational programs for professional formation.

Communication skills teaching in Brazilian medical schools: What lessons can be learned?

OBJECTIVE: To assess current practices in communication skills (CS) teaching in Brazilian medical schools (MS), looking for similarities and differences with other countries. METHODS: This study was performed with 162 out of the 237 accredited Brazilian MS (68.35%). The quantitative data were analyzed using descriptive statistics and qualitative data using content analysis. RESULTS: 104 MS (64.2%) reported formal CS training. CS were more commonly taught in the pre-clinical years, by physicians and psychologists. Compared to other countries, Brazil was unique in offering training for "acolhimento" ("embracement"), which is a Brazilian Government strategy that requires that all those connected with healthcare delivery, from administrators to practitioners, and all allied health personnel "embrace" a dedication to caring for patients and the communities in which they live. CONCLUSIONS: Formal CS teaching in Brazilian MS is less frequently seen in MS curriculum compared to reported data from other countries. The CS teaching of "embracement" is unique to Brazil. PRACTICE IMPLICATIONS: This study adds to the literature by identifying the CS teaching of "embracement" in Brazilian MS, which could be considered outside Brazil.

How Do Medical Schools Identify and Remediate Professionalism Lapses in Medical Students? A Study of U.S. and Canadian Medical Schools.

PURPOSE: Teaching and assessing professionalism is an essential element of medical education, mandated by accrediting bodies. Responding to a call for comprehensive research on remediation of student professionalism lapses, the authors explored current medical school policies and practices. METHOD: In 2012-2013, key administrators at U.S. and Canadian medical schools accredited by the Liaison Committee on Medical Education were interviewed via telephone or e-mail. The structured interview questionnaire contained open-ended and closed questions about practices for monitoring student professionalism, strategies for remediating lapses, and strengths and limitations of current systems. The authors employed a mixed-methods approach, using descriptive statistics and qualitative analysis based on grounded theory. RESULTS: Ninety-three (60.8%) of 153 eligible schools participated. Most (74/93; 79.6%) had specific policies and processes regarding professionalism lapses. Student affairs deans and course/clerkship directors were typically responsible for remediation oversight. Approaches for identifying lapses included incident-based reporting and routine student evaluations. The most common remediation strategies reported by schools that had remediated lapses were mandated mental health evaluation (74/90; 82.2%), remediation assignments (66/90; 73.3%), and professionalism mentoring (66/90; 73.3%). System strengths included catching minor offenses early, emphasizing professionalism schoolwide, focusing on helping rather than punishing students, and assuring transparency and good communication. System weaknesses included reluctance to report (by students and faculty), lack of faculty training, unclear policies, and ineffective remediation. In addition, considerable variability in feedforward processes existed between schools. CONCLUSIONS: The identified strengths can be used in developing best practices until studies of the strategies' effectiveness are conducted.

Efficacy of an internet-based learning module and small-group debriefing on trainees' attitudes and communication skills toward patients with substance use disorders: results of a cluster randomized controlled trial.

PURPOSE: To examine whether an Internet-based learning module and small-group debriefing can improve medical trainees' attitudes and communication skills toward patients with substance use disorders (SUDs). METHOD: In 2011-2012, 129 internal and family medicine residents and 370 medical students at two medical schools participated in a cluster randomized controlled trial, which assessed the effect of adding a two-part intervention to the SUDs curricula. The intervention included a self-directed, media-rich Internet-based learning module and a small-group, faculty-led debriefing. Primary study outcomes were changes in self-assessed attitudes in the intervention group (I-group) compared with those in the control group (C-group) (i.e., a difference of differences). For residents, the authors used real-time, Web-based interviews of standardized patients to assess changes in communication skills. Statistical analyses, conducted separately for residents and students, included hierarchical linear modeling, adjusted for site, participant type, cluster, and individual scores at baseline. RESULTS: The authors found no significant differences between the I- and C-groups in attitudes for residents or students at baseline. Compared with those in the C-group, residents, but not students, in the I-group had more positive attitudes toward treatment efficacy and self-efficacy at follow-up (P<.006). Likewise, compared with residents in the C-group, residents in the I-group received higher scores on screening and counseling skills during the standardized patient interview at follow-up (P=.0009). CONCLUSIONS: This intervention produced improved attitudes and communication skills toward patients with SUDs among residents. Enhanced attitudes and skills may result in improved care for these patients.

Preserving third year medical students' empathy and enhancing self-reflection using small group "virtual hangout" technology.

BACKGROUND: Medical student professionalism education is challenging in scope, purpose, and delivery, particularly in the clinical years when students in large universities are dispersed across multiple clinical sites. We initiated a faculty-facilitated, peer small group course for our third year students, creating virtual classrooms using social networking and online learning management system technologies. The course emphasized narrative self-reflection, group inquiry, and peer support. METHODS: We conducted this study to analyze the effects of a professionalism course on third year medical students' empathy and self-reflection (two elements of professionalism) and their perceptions about the course. Students completed the Groningen Reflection Ability Scale (GRAS) and the Jefferson Scale of Empathy (JSE) before and after the course and provided anonymous online feedback. RESULTS: The results of the JSE before and after the course demonstrated preservation of empathy rather than its decline. In addition, there was a statistically significant increase in GRAS scores (p < 0.001), suggesting that the sharing of personal narratives may foster reflective ability and reflective practice among third year students. CONCLUSION: This study supports previous findings showing that students benefit from peer groups and discussion in a safe environment, which may include the use of a virtual group video platform.

Residents' and standardized patients' perspectives on empathy: issues of agreement.

OBJECTIVE: We investigated correlations between residents' scores on the Jefferson Scale of Empathy (JSE), residents' perceptions of their empathy during standardized-patient encounters, and the perceptions of standardized patients. METHODS: Participants were 214 first-year residents in internal medicine or family medicine from 13 residency programs taking standardized patient-based clinical skills assessment in 2011. We analyzed correlations between residents' JSE scores; standardized patients' perspectives on residents' empathy during OSCE encounters, using the Jefferson Scale of Patient Perceptions of Physician Empathy; and residents' perspectives on their own empathy, using a modified version of this scale. RESULTS: Residents' JSE scores correlated with their perceptions of their own empathy during encounters but correlated poorly with patients' assessments of resident empathy. CONCLUSION: The poor correlation between residents' and standardized patients' assessments of residents' empathy raises questions about residents' abilities to gauge the effectiveness of their empathic communications. The study also points to a lack of congruence between the assessment of empathy by standardized patients and residents as receivers and conveyors of empathy, respectively. PRACTICE IMPLICATIONS: This study adds to the literature on empathy as a teachable skill set and raises questions about use of OSCEs to assess trainee empathy.

Changes in intern attitudes toward medical error and disclosure.

CONTEXT: The 2000 Institute of Medicine report, 'To Err is Human: Building a Safer Health System', focused the medical community on medical error. This focus led to educational initiatives and legislation designed to minimise errors and increase their disclosure. OBJECTIVES: This study aimed to investigate whether increased general awareness about medical error has affected interns' attitudes toward medical error and disclosure by comparing responses to surveys of interns carried out at either end of the last decade. METHODS: Two cohorts of interns for the academic years 1999, 2000 and 2001 (n = 304) and 2008 and 2009 (n = 206) at a university hospital were presented with two hypothetical scenarios involving errors that resulted in, respectively, no permanent harm and an adverse outcome. The interns were questioned regarding their likely responses to error and disclosure. RESULTS: We collected 510 surveys (100% response rate). For both scenarios, the percentage of interns who would be willing to fully disclose their mistakes increased substantially from 1999-2001 to 2008-2009 ('no permanent harm': 38% and 71%, respectively [p < 0.001]; 'adverse outcome': 29% and 55%, respectively [p < 0.001]). About two thirds of fully disclosing interns in both scenarios believed 'the patient's right to full information' to be the primary reason for their disclosure. Fear of litigation in response to error disclosure decreased (70% and 52%, respectively), the percentage of interns who felt that 'medical mistakes are preventable if doctors know enough' decreased (49% and 31%, respectively), belief that competent doctors keep emotions and uncertainties to themselves decreased (51% and 14%, respectively), and agreement with leaving medicine if one (as an intern) caused harm or death decreased (50% and 3%, respectively). Prior training about medical mistakes increased more than four-fold between the cohorts. CONCLUSIONS: This comparison of intern responses to a survey administered at either end of the last decade reveals that there may have been some important changes in interns' intended disclosure practices and attitudes toward medical error.

Returning physicians to the workforce: history, progress, and challenges.

There is growing recognition of the need to reeducate clinically inactive physicians seeking to return to practice and in the facilitation of this return. Physicians seeking to return to practice face many challenges: maneuvering the various requirements of licensing, medical, and credentialing boards; finding an appropriate educational program to become up to date in current practice; paying for the program; and overcoming personal obstacles. Educational programs also face challenges: cost of development and maintenance; allocation of staff and faculty time to reeducate returning physicians alongside other learners; provision of emotional counseling and career guidance; interpretation of varied licensing and board guidelines; and the need to tailor one's program to individual trainees. Despite these challenges, some programs are returning physicians to the workforce. To provide perspective, we review why physicians leave medicine and return. We then discuss challenges for returning physicians and program developers and highlight current educational resources and organizational efforts to facilitate return. We close by offering next steps for programs to facilitate return.

Assessment of an innovative instructional program to return non-practicing physicians to the workforce.

INTRODUCTION: Few formal educational programs are available in the United States to assist physicians wishing to return to medical practice after clinical inactivity. Little published data on physicians who complete these programs exist. We describe the Drexel Medicine Physician Reentry/Refresher course and present our findings on participant demographics, performance, and goal attainment following course completion. METHODS: Physician self-assessment, future career goals, recommendations of referring organizations, and a quantitative assessment of knowledge and skills were used to create individualized learning objectives and physician's curriculum. Initial assessment included demonstration of clinical skills using standardized patients and medical knowledge using the National Board of Medical Examiners Comprehensive Clinical Medicine Self-Assessment Examination. Progress in knowledge and clinical skills was measured by repeat assessment at course completion. We questioned physicians 3 months after course completion to determine if initial goals were attained. RESULTS: Thirty-six physicians completed the program from November 2006 through November 2010. Most physicians demonstrated significant improvement in core clinical skills and knowledge at the end of the course. All physicians who sought employment, hospital privileges, and refreshing skills as initial goals were successful. CONCLUSION: The Drexel Medicine Physician Reentry/Refresher course provides a unique model for successfully returning inactive physicians to clinical practice.

eLearning to enhance physician patient communication: a pilot test of "doc.com" and "WebEncounter" in teaching bad news delivery.

BACKGROUND: Physician-patient communication skills help determine the nature and quality of diagnostic information elicited from patients, the quality of the physician's counseling, and the patient's adherence to treatment. In spite of their importance, surveys have demonstrated a wide variability and deficiencies in the teaching of these skills. AIM: Describe two specific methodologies for teaching physician-patient communication skills developed at our institution and pilot test them for effectiveness. METHODS: Between 2004 and 2009 we developed "doc.com," a series of 41 media-rich online modules on all aspects of healthcare communication jointly with the American Academy on Communication in Healthcare. Starting in 2006, we expanded our pre-existing experience with the videoconferencing system "WebOSCE" into the online application "WebEncounter." This new methodology combines practice of communication skills on standardized patients with structured assessment and constructive feedback. We had three randomized groups: controls who did only the assessment parts of a WebOSCE on two occasions, a doc.com group who had doc.com in between the assessment occasions, and a combined group that had both doc.com and a WebEncounter between assessments. RESULTS/CONCLUSION: We found significant improvement in skills as components were added, and the training program was well received.

Psychosomatic medicine: the scientific foundation of the biopsychosocial model.

OBJECTIVE: This article presents major concepts and research findings from the field of psychosomatic medicine that the authors believe should be taught to all medical students. METHOD: The authors asked senior scholars involved in psychosomatic medicine to summarize key findings in their respective fields. RESULTS: The authors provide an overview of the field and summarize core research in basic psychophysiological mechanisms-central nervous system/autonomic nervous system, psychoneuroimmunology, and psychoendocrinology-in three major disease states-cardiovascular, gastrointestinal, and HIV virus infections. CONCLUSIONS: Understanding the core scientific concepts and research findings of psychosomatic medicine should provide medical trainees with a scientific foundation for practicing medicine within a biopsychosocial model of care.

The impact of the changing health care environment on the health and well-being of faculty at four medical schools.

PURPOSE: Increased pressure for clinical and research productivity and decreased control over the work environment have been reported to have adverse impacts on academic faculty in limited studies. The authors examined whether work-related stressors in academic medicine negatively affected the physical and mental health, as well as life and job satisfaction, of academic medical school faculty. METHOD: A 136-item self-administered anonymous questionnaire modified from a small 1984 study was distributed to 3,519 academic faculty at four U.S. medical schools following institutional review board approval at each school. Validated scales measuring depression, anxiety, work strain, and job and life satisfaction; a checklist of common physical and mental health symptoms; and questions about the impact of institutional financial stability, colleague attrition, and other work-related perceptions were used. Responses were analyzed by sex, academic rank, age, marital status, faculty discipline, and medical school. RESULTS: Responses were received from 1,951 full-time academic physicians and basic science faculty, a 54.3% response rate. Twenty percent of faculty, almost equal by sex, had significant levels of depressive symptoms, with higher levels in younger faculty. Perception of financial instability was associated with greater levels of work strain, depression, and anxiety. Significant numbers of faculty acknowledged that work-related strain negatively affected their mental health and job satisfaction, but not life satisfaction or physical health. Specialties were differentially affected. CONCLUSIONS: High levels of depression, anxiety, and job dissatisfaction-especially in younger faculty-raise concerns about the well-being of academic faculty and its impact on trainees and patient care. Increased awareness of these stressors should guide faculty support and development programs to ensure productive, stable faculty.

A survey of residents' attitudes and practices in screening for, managing, and documenting domestic violence.

OBJECTIVE: We conducted this study to identify residents' limitations in screening for, documenting, and managing domestic violence (DV) and to focus future educational interventions. METHODS: We administered a detailed survey to 103 internal medicine residents from 4 university-affiliated programs to ascertain their attitudes about and practices in screening for, documenting, and managing DV. RESULTS: Most residents agreed that DV is a significant health care problem (87%) and one in which physicians can intervene effectively (77%), yet 37% reported not screening for DV. Residents who said they do not screen reported a variety of mitigating factors, from uncertainty about how to screen for and manage DV, to fear of insulting or angering the patient. Eighty-two percent stated that they would document DV in the chart, but 51% had reasons for not documenting DV, ranging from fear that the patient's partner might harm the patient or the physician to concern that the patient may not be telling the truth. Fifty-seven percent of residents said they would ask about DV more often if state law mandated it. When asked to choose which management interventions were helpful or unhelpful, many residents made incorrect, potentially injurious choices. CONCLUSION: Many residents reported beliefs and practices that could inhibit optimal care of DV victims. Educational interventions should be directed at remedying residents' gaps in knowledge and attitudes to improve screening for, documenting, and managing DV.

Realizing Engel's vision: psychosomatic medicine and the education of physician-healers.

Many of the exciting conceptual and scientific advances in the field of psychosomatic medicine are not taught in United States medical schools. This article, based on the Presidential Address given at the Annual Meeting of the American Psychosomatic Society in Phoenix, Arizona in March 2003, reviews the rationale for integrating psychosomatic medicine into medical curricula, identifies educational needs, proposes a core curriculum, and suggests how American Psychosomatic Society members can be instrumental in curriculum development and implementation.

Evaluating surgeons' informed decision making skills: pilot test using a videoconferenced standardised patient.

BACKGROUND: Standardised patients (SPs) are effective in evaluating communication skills, but not every training site may have the resources to develop and maintain SP programmes. OBJECTIVES: To test whether videoconferencing technology (VT) could enable an interaction between an SP and an orthopaedic surgeon that would allow the SP to accurately evaluate the surgeon's informed decision making (IDM) skills. We also assessed whether this sort of interaction was acceptable to orthopaedic surgeons as a means of learning IDM skills. METHODS: We trained an SP to represent a 75-year-old woman considering hip replacement surgery. Orthopaedic surgeons in Chicago individually consulted with the SP in Philadelphia; each participant could see and hear the other on large television screens. The SP evaluated the surgeons' advice using a 23-item checklist of IDM elements, and gave each surgeon verbal and written feedback on his IDM skills. The surgeons then gave their evaluations of the exercise. RESULTS: Twenty-two surgeons completed the project. The SP was > or = 80% accurate in classifying 20 of the 23 IDM skills when compared to a clinician rater. Although 12 (55%) of the orthopaedic surgeons felt that some aspects of the technology were distracting, most were pleased with it, and 19 of 22 (86%) would recommend the videoconferenced SP interaction to their colleagues as a means of learning IDM skills. CONCLUSIONS: These results suggest that VT allows accurate evaluation of IDM skills in a format that is acceptable to orthopaedic surgeons. Videoconferencing technology may be useful in long-distance SP communication assessment for a variety of learners.

A pilot test of WebOSCE: a system for assessing trainees' clinical skills via teleconference.

WebOSCE is a computer-based system that allows a student at an affiliate site to participate in a 10-station standardized patient-based exam using a videoconference interface, while nine other students take the exam on-site. We pilot-tested this system during a required year-end objective structured clinical exam. We compared performance data between the 26 distance students taking the exam via WebOSCE with 221 on-site students. We also compared both student groups' responses on a post-exam questionnaire, and conducted a post-exam structured interview to elicit the Pittsburgh students' perspectives on the WebOSCE experience. Students taking the exam via WebOSCE scored significantly lower in most categories except for physical exam and information-giving skills, on which the groups did not differ. There were no differences between groups in students' overall evaluation of the exam experiences. In general, Pittsburgh students rated WebOSCE highly and offered many helpful comments to improve the technology and the experience.

An assessment of residents' abilities to detect and manage domestic violence.

Despite increased awareness of domestic violence (DV), little is known about residents' preparedness to diagnose and respond appropriately to abuse victims. We designed a pilot study to examine this. Seventy-one internal medicine residents participated in a 10-station standardized patient-based Clinical Skills Assessment. Forty (56%) were male and 31 (44%) were female; 46 (65%) were PGY I; 63 (89%) were trained internationally. One station presented a woman with headaches, whose underlying issue was DV. Forty (56%) residents correctly diagnosed DV. Thirty referred the patient for DV counseling. Eighteen addressed immediate safety concerns, and 23 asked about child abuse. Forty-eight (68%) made 1 or more incorrect recommendations. Thirty-six (51%) ordered unnecessary tests. Residents who did not diagnose DV spent nearly twice as much per patient on work-up (mean, $942.00), compared to those who diagnosed DV (mean, $421.00). Use of certain interviewing skills appeared to promote elicitation of DV. Assessment-driven educational interventions could help trainees improve their recognition of DV and make appropriate and cost-effective management choices.