The effectiveness of using standardized patients to improve community physician skills in mammography counseling and clinical breast exam.

BACKGROUND: Traditional didactic continuing education is relatively ineffective in improving physicians' clinical skills. We hypothesized that a centralized course including small group workshops utilizing standardized patients could improve clinical skills for a reasonable cost. METHODS: We designed a 5-h course aimed at improving physicians' counseling skills (re: screening mammography) and clinical breast exam (CBE) skills. The course included lectures, demonstrations, and small group skills sessions utilizing standardized patients and was offered to 156 typical community-based primary care physicians. Pre- and postcourse evaluation included in-office assessments of physician CBE and counseling performance by standardized patients and a written test of knowledge and attitudes. RESULTS: A total of 54.5% of eligible physicians participated. They improved modestly in only one of three areas of counseling skills measured (providing counseling appropriate to the patient's readiness to accept mammography, P = 0.01). The overall CBE score increased substantially from 24.8 to 34.7 (P < 0.0001). Knowledge in all areas measured and confidence in counseling patients also increased. The basic course cost $202 per physician trained. CONCLUSIONS: Most community-based primary care physicians may find small group training and in-office evaluation involving standardized patients acceptable. Such training may be more effective in improving physical exam skills than complex communication skills.

The standardized family: an innovation in primary care education at the University of Massachusetts.

In 1995 as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative, the University of Massachusetts (UMass) Medical School developed the "standardized family" as a new model for teaching the essential elements of primary care in a core curriculum format outside of the clinical setting. Using this model, a hypothetical family unit (the "McQ Family") serves as the focus for case-based clinical problem solving. This paper describes the standardized family model and provides two years of evaluation outcomes such as curriculum assessments, student performance outcomes, and correlation with external measures of clinical performance to support the effectiveness of this educational model. It discusses the transferability of the standardized family model from UMass Medical School to Pennsylvania State University College of Medicine and uses Pennsylvania State's adaptation (the "Hershey-Penn Family") to illustrate how the standardized family can be customized to integrate a core curriculum into a three-year longitudinal primary care program. The authors suggest that the standardized family model has the potential to meet a broad range of primary care teaching needs at other institutions.

Evaluation of primary care futures: a faculty development program for community health center preceptors.

PURPOSE: To assess the impact of a national series of faculty development workshops for community health center preceptors. METHOD: Two hundred and twenty-three community health center preceptors from a variety of disciplines attended one of five workshops conducted in different regions of the country. The workshops emphasized active learning using role-play to provide skills in educational planning, teaching styles, evaluation, and feedback. The preceptors were evaluated before and immediately after the workshop, and again three months later. They were also asked to assess the quality of the workshop. RESULTS: The preceptors demonstrated significant increases in the use of five of seven teaching concepts while analyzing a role-play interaction. In addition, there were significant positive, immediate changes in familiarity with nine of 11 concepts, which were retained for at least three months. The preceptors also reported that they continued to use six of the effective teaching behaviors they had learned three months after the workshop. They were extremely positive in their assessments of the workshops. CONCLUSION: This preliminary study suggests that preceptors from a variety of backgrounds can improve their teaching knowledge and skills by participating in a brief faculty development program that emphasizes active learning.

Clinical teaching improvement: past and future for faculty development.

Faculty development programs have focused on the improvement of clinical teaching for several decades, resulting in a wide variety of programs for clinical teachers. With the current constraints on medical education, faculty developers must reexamine prior work and decide on future directions. This article discusses 1) the rationale for providing faculty development for clinical teachers, 2) the competencies needed by clinical teachers, 3) the available programs to assist faculty to master those competencies, and 4) the evaluation methods that have been used to assess these programs. Given this background, we discuss possible future directions to advance the field.

Physician training for patient-centered nutrition counseling in a lipid intervention trial.

BACKGROUND: We examined the effect of a 3-hr training program on physicians' lipid intervention knowledge, attitudes, and skills. The program teaches physicians skills to conduct a brief dietary risk assessment and provide patient-centered counseling to enable patients with elevated lipids to change their dietary patterns. METHOD: The training is part of a randomized trial of lipid-lowering interventions, the Worcester Area Trial for Counseling in Hyperlipidemia. Primary care internists practicing in a health maintenance organization (HMO) were assessed, before and after training using questionnaires and audiotapes to document changes in knowledge about diet, attitudes about intervention, reported nutrition intervention practices, and counseling and assessment skills. Physicians also rated the value that they thought the training program had to them. RESULTS: After completion of the program the physicians' use of dietary counseling steps, as assessed by blinded evaluation of audiotaped physician-patient interactions, significantly increased (mean pre = 5.4, mean post = 9.2; t = 9.9; P < or = 0.001). In this regard, there were instances in the use of 7 of the 14 specific counseling steps. Physicians also demonstrated increases in self-perceived preparedness as measured by a 5-point scale (mean pre = 3.2, mean post = 4.0; t = 4.25; P < 0.001), confidence in having an effect (mean pre = 3.3, mean post = 3.9; t = 3.16; P < 0.01), perception that materials were available to aid intervention (mean pre = 2.7, mean post = 4.0; t = 5.29; P < 0.001), and perception that they have access to a nutritionist (mean pre = 3.5, mean post = 4.0; t = 2.63; P < 0.01). They rated the value of the program between very good and excellent. CONCLUSION: Results of this 3-hr educational program indicate that physicians in an HMO are responsive to the teaching of specialized skills deemed important for promoting health behavior change in their patients.

Magnetic resonance imaging use by primary care physicians.

BACKGROUND: Magnetic resonance imaging (MRI) has recently been introduced in the United States as an imaging technique for clinical use. Initially used by neurologists to view the brain stem, its indications have rapidly expanded to include spine, pelvis, bone marrow, and joints. This has raised concerns over the appropriate, cost-effective use of such an expensive technology. This paper examines MRI scanning patterns that have developed over time in central Massachusetts and surveys primary care knowledge, attitudes, and patterns of utilization. METHODS: The two MRI centers in central Massachusetts were surveyed for information about the number and types of scans ordered and the specialties of the physicians who ordered the scans. Questionnaires were sent to primary care physicians in Worcester County to assess knowledge and attitudes about MRI and utilization. RESULTS: The data demonstrate changing patterns of MRI utilization over time. Orthopedics has been the specialty with the greatest increase in use, now slightly surpassing neurology in the total number of scans ordered. Primary care physician use has doubled over this same period. Not all primary care physicians utilize MRI, but those who have used the technology have familiarized themselves with its indications and problems and have a better knowledge about its costs. CONCLUSIONS: Utilization patterns of MRI have changed considerably in a short time, with primary care physicians requesting use of this new technology much more frequently than when it was first introduced.

Evaluation of two AIDS prevention interventions for inner-city adolescent and young adult women.

Two hundred and fourteen young women received acquired immunodeficiency syndrome (AIDS) prevention interventions at an inner-city family health center serving minority patients predominantly. The community in which the health center is located has a high incidence of intravenous (IV) drug abuse. Either a peer or a health care provider delivered the intervention. In the peer-delivered intervention, a trained peer educator reviewed with patients an AIDS "Rap" videotape and several AIDS brochures, which imparted information about human immunodeficiency virus (HIV), its transmission, and prevention. In the provider-delivered intervention, family practice residents, attending physicians, and nurse practitioners used a patient-centered counseling approach to convey the same information. Questionnaires administered immediately before and after the intervention and at one month follow-up evaluated changes in knowledge, attitudes, and behavior. Analyses of data from both combined intervention groups revealed significant improvements in several areas of knowledge, including the effectiveness of using a condom and cleaning IV drug implements with bleach to prevent transmission of HIV. Many improvements were retained at the one-month follow-up. In addition, subjects in both groups who were sexually active stated immediately after the intervention that asking a sexual partner about past sexual experience would now be less difficult, and at one-month follow-up they reported a significant decrease in the frequency of vaginal sex. Our findings suggest that counseling by physicians can achieve more changes in knowledge of sexual risks, whereas peer education can achieve greater changes in knowledge about IV drug use. Results show that both approaches to AIDS prevention used in this study can significantly affect knowledge, attitudes, and sexual behavior.

PIP: 214 women of average age 20.3 years were subject to an AIDS prevention intervention at a family health center in a high IV drug use community in Worcester, Massachusetts. 116 of the women learned about HIV, its transmission, and prevention with trained peer educators in a review of an AIDS "Rap" video and several AIDS brochures. The remaining 98 women were exposed to the same information, but in a patient-centered counseling approach with family practice residents, attending physicians, and nurse practitioners. 25 women were African-American, 105 Caucasian, 76 Hispanic, and 8 of other ethnic backgrounds. They answered questionnaires regarding their AIDS-related knowledge, attitudes, and practices immediately before, immediately after, and 1 month after exposure to either the peer educator or provider-based education sessions; only 97 completed the follow-up survey. The authors found knowledge on the effectiveness of using condoms and cleaning IV drug implements with bleach to prevent HIV transmission to have significantly improved following the interventions. Many improvements remained at the 1-month follow-up. Moreover, sexually active subjects in both groups noted immediately after the interventions that they would find it easier to ask sex partners about past sexual experiences. A significant decrease was also reported in the amount of vaginal sex at the 1-month follow-up. The authors conclude that while physician counseling may effect more change in the knowledge of sexual risks, peer education may better effect change in knowledge about IV drug use.

The impact of JRA on children, adolescents, and their families. Current research and implications for future studies.

This article focusses on the impact of Juvenile Rheumatoid Arthritis (JRA) on children, adolescents, and their families. Investigations reported in the literature that consider the etiologic role of psychopathology and JRA, psychologic adjustment/maladjustment of adolescents with JRA, family adaptation to chronic illness, and changes in the family that affect health outcomes and treatment compliance are critically reviewed. Methodologic and research design issues are discussed in relation to previous investigations, and implications for future research are presented.

Evaluation of three psychologic interventions to reduce anxiety during MR imaging.

The authors compared the effectiveness of three anxiety-reducing interventions for patients undergoing magnetic resonance imaging. Each of 50 subjects was randomly assigned to one of the interventions. Intervention 1 involved provision of information about the imager and nature of the examination. Intervention 2 included information and counseling. Intervention 3 included information and a 12-minute relaxation exercise. Anxiety levels were measured by means of a 20-item questionnaire before and after imaging. The latter provided a retrospective report of anxiety experienced during imaging. Patients in intervention group 3 showed significantly less increase in anxiety compared with those in groups 1 and 2. Overall, only patients who participated in intervention 1 showed a significant increase in anxiety during imaging. When anxiety levels experienced before and during the examination were compared, with the focus on each questionnaire item for each group, those in group 1 showed a significant increase in anxiety on eight of 20 items; those in group 2, three items; and those in group 3, none. Psychologic preparation that includes relaxation strategies is more effective than provision of information alone.

Anxiety in patients undergoing MR imaging.

To determine and quantify the major sources of anxiety for patients undergoing magnetic resonance (MR) imaging and to suggest means by which to eliminate or diminish their negative effects, the authors studied anxiety in 46 subjects. Of these, 20 randomly selected subjects who successfully completed the examination participated in exit interviews. Six subjects who terminated the examination before completion also completed exit interviews. Pre-imaging and postimaging questionnaires (state-trait anxiety inventory) were administered to measure anxiety in the 20 other subjects. Anxiety was associated with the constrictive dimensions of the magnet bore, examination duration, coil noise, and temperature within the bore. Preparation at the point of referral was consistently absent, incomplete, or misleading. Patients used identifiable strategies to cope with the examination: blinding, breathing relaxation techniques, visualization of pleasant images, and performance of mental exercises.

A residents' training program for the development of smoking intervention skills.

This article describes the results of a three-hour training program that teaches residents a patient-centered counseling approach to smoking cessation, emphasizing questioning and exploring feelings, rather than providing information. Fifty internal medicine and family practice residents affiliated with a university medical center were assessed before and after training using questionnaires and videotape documenting changes in their knowledge about smoking, attitudes concerning intervention, and intervention skills. The residents showed a significant increase in knowledge and perceived themselves as having significantly more influence on their patients who smoke after completion of the training program. Counseling skills improved significantly in the use of questions and exploring feelings as judged by blind evaluation of videotapes. The results of this three-hour training program suggest that physicians in training are responsive to the teaching of specialized skills deemed important for promoting health behavior changes in their patients.

Simulated versus actual patients in teaching medical interviewing.

This research project investigates the value of using simulated v. real patients in teaching interviewing skills to third- and fourth-year medical students on a clerkship in family and community medicine. Sixty-four medical students (38 males, 28 females) were asked to make a videotaped patient interview at the beginning of the clerkship. Forty-one of the students interviewed trained, simulated patients and 22 interviewed real patients at their clerkship site. Students received feedback and faculty teaching of interviewing skills after the first interview. All students made another videotaped interview with a simulated patient at the conclusion of the clerkship. All interviews, pre- and post-clerkship, were scored for interviewing skills, focal areas, and nonverbal language. Multivariate and univariate analyses of pre- and post-interviews found simulated patients to be of most value in teaching medical students verbal interviewing skills and real patients to be of most value in teaching the focal content areas of the interview. Recommendations were made to include use of both simulated and real patients in the teaching of medical interviewing.

Teaching styles in the faculty-resident relationship.

As part of an effort to train family physicians to be more effective teachers in family medicine, a teaching styles workshop program was developed. The aim of the program is to help physician teachers to become more flexible in matching a teaching style to a particular teaching context. The program consists of three components: (1) a scheme for classifying teaching behaviors as belonging to one of the four basic styles identified, (2) videotaped models of each of the four basic styles, and (3) structured role playing by workshop participants in which the four styles are practiced and critiqued. The program, as used in two different sets of faculty development workshops, is described and recommendations for its use by others given.