Education in ambulatory settings: developing valid measures of educational outcomes, and other research priorities.

Efforts to redesign education in ambulatory settings are hampered by a lack of rigorous and coherent research on the learning process in these settings and the desired outcomes of the educational experiences. The authors present 13 priority research topics and 51 important research questions concerning education in ambulatory settings that were defined by a distinguished group of medical educators, clinicians, and policymakers who attended an invitational conference on education in ambulatory settings in 1996. The need to establish valid and reliable measures of quality and outcomes of educational programs and instructional interventions stood out as the major prerequisite for conducting research on education in ambulatory settings. Issues of theory building, research priorities, and research design are discussed, and policy recommendations are made for the development of valid measures of educational outcomes. The creation of a "Medical Education Outcomes Commission" is proposed to act as a repository for measures and instruments, and to provide the field with mechanism to validate instruments and uniform recommendations to conduct studies of quality. The authors urge funding agencies with missions that support medical education to invest in basic research on the outcomes of education in ambulatory settings.

A study of medical students' specialty-choice pathways: trying on possible selves.

PURPOSE: To describe the decision-making processes reported by graduating medical students in choosing primary care (PC) or non-primary-care (NPC) specialties. METHOD: Members of the University of Washington School of Medicine's graduating class of 1995 were invited to participate in focus groups. Six specialty-choice pathways were defined based on a previously administered survey of recalled preferences at matriculation and stated choice at the time of the National Resident Matching Program. Students were assigned to focus groups based on specialty-choice pathway. Transcribed discussions and summaries were thematically coded and analyzed using grounded theory and quantitative comparisons. RESULTS: Of 157 students, 140 (89%) completed the initial survey, and 133 (85%) provided enough information to be classified by pathway. In all, 47 students participated in the focus group discussions. The PC students cited PC orientation, diversity of patients and activities, role models and mentors, interaction with patients, and overall medical school culture as having influenced their choice. The NPC students cited lifestyle, controllable hours, opportunities to do procedures, therapeutic urgency and effect, active tempo, exciting settings, and intellectual challenge. Role models influenced PC career choice much more than NPC career choice, and often served to refute negative stereotypes. The sense of personal fit between themselves and specialties was important to the students in all groups, but differed in emphasis according to career-choice pathways. Those whose preferences did not change experienced a confirmation of pre-existing beliefs, while those who switched specialty areas developed a sense of fit through the inclusion or elimination of different practice aspects. Those who switched specialty areas reported more negative influences and misunderstanding of their initially preferred specialties. CONCLUSION: The process of specialty choice can be described usefully as a socially constructed process of "trying on possible selves" (i.e., projecting oneself into hypothetical career and personal roles). This may explain role models' exceptional influence in disproving negative stereotypes. Medical students' choices can best be facilitated by recognizing their needs to gain knowledge not only about specialty content, but also about practitioners' lives and the students' own present and possible selves.

Types of faculty development programs.

This paper offers an overview of faculty development program types, with references to specific programs described in the recent literature. Faculty development programs have been categorized in a number of ways. This review uses a variation of those typologies and suggests six types of faculty development activities: 1) organizational strategies, 2) fellowships, 3) comprehensive local programs, 4) workshops and seminars, 5) continuing medical education, and 6) individual activities. While these categories provide a conceptual basis for distinguishing among programs, actual programs in use often contain elements of more than on type.

Assessment of faculty development program outcomes.

BACKGROUND AND OBJECTIVES: More and better research is needed about the effectiveness of faculty development programs. Increasingly, government leaders in Congress and the Administration expect comprehensive outcome and impact evaluation as justification for federal finding. This paper summarizes outcomes reported and methods used in published studies of faculty development programs since 1980.

Outcomes of three part-time faculty development fellowship programs.

BACKGROUND AND OBJECTIVES: Part-time faculty development fellowship programs have trained large numbers of new physician faculty for family medicine education programs. This study reviews data from three part-time fellowship programs to determine how well the programs train new faculty and the academic success of fellowship graduates. METHODS: Part-time fellowship programs at Michigan State University, the University of North Carolina, and the Faculty Development Center in Waco, Tex, sent written surveys to graduates as part of routine follow-up studies. Graduates were asked to report their current status in academic medicine, how they spend their time, measures of academic productivity, and assessments of how well their training prepared them for their current academic positions. Data were complied at each institution and sent to Michigan State University for analysis. RESULTS: The majority of graduates (76%) have remained in their academic positions, and half (49%) teach in medically underserved settings. Graduates report high levels of satisfaction with the training they received. Thirty-two percent of graduates have published peer-reviewed articles, and almost 50% have presented at peer-reviewed meetings. CONCLUSIONS: Part-time fellowship programs have been successful at training and retaining large numbers of new faculty for family medicine.

Collegial networking and faculty vitality.

BACKGROUND: This research explored the relationship between collegial networking and faculty "vitality" among graduates of the family medicine faculty development fellowship at the University of North Carolina at Chapel Hill. Faculty vitality was defined by retention in full-time teaching, job satisfaction, academic activity, and contributions to the discipline. METHODS: A questionnaire was mailed to 170 family physician graduates of the 1980-1992 fellowship classes. After a mail and telephone follow-up, the response rate was 85%. Data were collected on career history, professional interests, professional relationships, assessment of fellowship, and professional activities. RESULTS: Respondents with collegial networks were more likely to participate in several academic activities and were more likely to remain in full-time teaching. No association was found between collegial networks and satisfaction or contributions to the discipline. There were only small differences in effect between intra-departmental and extra-departmental collegial networks. Stratification by program type and gender revealed no evidence of effect modification or confounding. CONCLUSIONS: Collegial networks influence some aspects of faculty vitality, particularly retention in full-time teaching. Further research is needed to fully understand its impact.

Role models' perceptions of themselves and their influence on students' specialty choices.

PURPOSE: To examine the perceptions of faculty role models to learn whether their perceptions of role models' behaviors are congruent with those of their students. METHOD: In 1996 a survey was mailed to 210 student-identified faculty role models at the University of Washington School of Medicine and the University of North Carolina at Chapel Hill School of Medicine. The nominees were asked to rate to what extent each of 32 student-identified role model characteristics was representative of their behavior. They were then asked to rank order the characteristics they felt were most important to model for students. The role models were also asked to rate how much influence they perceived themselves to have on their students' specialty choices. A final, open-ended question inquired about the single characteristics they modeled to students that most influenced the students' specialty choices. The role models' specialties were grouped as either primary care (PC) or non-primary care (NPC). Data were analyzed with several statistical methods. RESULTS: Of the 210 mailed surveys, a total of 177 were returned, for a response rate of 84%. The role models perceived their behaviors much like their students did; the role models' self-ratings were generally high for all of the student-defined characteristics. Although clinical reasoning was considered the most important characteristic to model for students, the role models also believed that enthusiasm and love for their work were the characteristics that most influenced their students' specialty choices. Few differences were found between the PC and the NPC role models. CONCLUSION: The role models in this study agreed with their students about what is important to model. They did not intentionally try to recruit students to join their specialties but felt that demonstrating enthusiasm and a sincere love for what they did has a strong influence toward this end.

Teaching dietary counseling skills to residents: patient and physician outcomes. The CADRE Study Group.

Our objective was to determine whether an educational intervention and prompting intervention for physicians improved dietary counseling of patients with high blood cholesterol and resulted in beneficial changes in patients' diets and cholesterol levels. We instituted a factorial design, multicenter, randomized, placebo-controlled trial to test two interventions. We tested the trial at continuity care clinics of internal medicine residents at seven community and university medical centers in the northern and eastern United States. Our participants were 130 internal medicine residents and 254 adult outpatients with blood cholesterol levels of 240-300 mg/dL. Interventions included an educational program for resident physicians designed to improve their skills and confidence in dietary counseling (two one-hour sessions with specially prepared printed materials for use in counseling) and a prompting intervention, which was a fingerstick blood cholesterol determination prior to the patient's clinic visit. Resident physicians' knowledge, attitudes, and self-reported behaviors were assessed prior to the intervention and 10 months later using chart audits and questionnaires. Residents' behaviors were also assessed by exit interviews with patients. Patients' knowledge, attitudes, behaviors, and fingerstick blood cholesterol levels were measured at baseline and 10 months later. The educational program increased the percentage of physicians who were confident in providing effective dietary counseling (baseline of 26% to 67%-78%; P < .01). The prompting intervention approximately doubled the frequency of physician counseling (P = .0005) and increased the likelihood that patients would try to change their diets. When both interventions were combined, most outcomes were better, although not statistically significant. Cholesterol levels, however, decreased only marginally and were no different among groups at 10-month follow-up. Despite success in changing physicians' attitudes and behaviors and increasing patients' willingness to change their diets, there was no significant change in patients' cholesterol levels. Medical Subject Headings (MeSH): randomized controlled trial; cholesterol; patient education; behavior therapy; education, medical; diet.

A comprehensive curriculum for thoracic surgery: survey of opinions from program directors and residents.

BACKGROUND: The Comprehensive Thoracic Surgery Curriculum was developed to provide program directors with a basis for planning instruction and evaluating residents, program practices, and outcomes. A survey design was selected to obtain opinions about the curriculum from a large group of people, ie, all program directors and all active residents. METHODS: Two parallel instruments were developed: one to be completed by program directors and one to be completed by active residents. Responses were collated for directors and residents, entered into a computerized database, and compared using the chi 2 statistic. RESULTS: A response rate of 93% was obtained from the directors and 79% from the residents. The survey demonstrates broad-based support for a comprehensive curriculum by the respondents. Current perceptions of and expectations for the curriculum are diverse and regionalized. Serious concerns are expressed about quality issues and particularly the environment for residency education. CONCLUSIONS: The thoughtful responses of our colleagues will guide leaders who will implement the curriculum for thoracic surgery. Strategies for change will necessarily focus on the prerequisite curriculum.

Learning contracts in clinical education.

This study explored the outcomes of using learning contracts in a radiologic science program. Telephone surveys of contract learning participants and other radiologic science graduates provided data regarding graduate career satisfaction, lifelong learning habits and attitudes toward learning. Statistical comparison data found that contract learning participants reported higher job satisfaction, participated more in continuing education, demonstrated more self-motivation and independence, felt less competitive and anxious about courses and grades and felt more involved in their clinical courses.

Research and practice in medical education.

Education should be practiced with attention to principles derived from both the research in medical education and the practical experience of health professions instructors. The authors summarize both the major questions addressed by researchers in medical education during recent years and some of the answers. This paper is divided into four major categories of questions that correspond to the areas of an instructor's responsibility: 1) curricular trends, 2) instruction, 3) evaluation of learners, and 4) evaluation of teaching. It focuses largely on the undergraduate medical curriculum, although many of the conclusions could be applied to graduate education as well.

Systematic survey of opinion regarding the thoracic surgery residency.

To summarize this rather wide-ranging study, let us review the high points. The future practice of thoracic surgery will be increasingly affected by governmental factors and will have even greater technological dimensions. To do this work, we must continue to attract high-caliber individuals, and this is best accomplished by the early and continuing involvement in the educational process of strong role models from our field. These future surgeons must be motivated to do good work and should have high ethical standards as well as maturity and high intelligence. Experienced, involved faculty leading the residents through a broad program that offers graduated assumption of clinical and leadership responsibilities will facilitate the development of mature clinical judgment. Residents must be taught the clinical skills necessary to do all thoracic operations, leaving subspecialization to postresidency fellowships. The educational program should be humane in its demands and collegial in its application. It should incorporate experiences beyond the operating room, including the opportunity to read, think, and interact with local mentors and colleagues from around the country. The requirements of certification should not be so rigid as to preclude the development of different pathways to the same end. Likewise, although the accreditation process must protect the resident from exploitation, it must not be so restrictive that it does not allow for educational innovation and justifiable differences among programs. These are the thoughtful opinions of our colleagues. They deserve serious consideration.

Faculty development in the health professions: conclusions and recommendations.

This report summarizes recent literature reviews and resource books on faculty development in the health professions and describes findings from articles not previously reviewed. Nine conclusions about faculty development in the health professions are drawn: (1) the concept of faculty development is evolving and expanding; (2) research skills are becoming a major focus of faculty development; (3) teaching skills are still a prominent aspect of faculty development; (4) fellowships are being used effectively to recruit and train new faculty; (5) the institutional environment has become a focus of faculty development; (6) faculty evaluation is an effective approach to faculty development; (7) the efficacy of faculty development needs better research documentation; (8) model curricula have been developed for different types of faculty; and (9) comprehensive faculty development centers are gaining in popularity. A set of recommendations based on the conclusions drawn is offered for those planning faculty development interventions.

Outcomes of a faculty development fellowship in family medicine.

This report describes a comparative evaluation of outcomes of a faculty development fellowship program in family medicine at the University of North Carolina. Rates of participation in academically oriented professional behavior are compared between family physicians who participated in the program and peers who did not. Results indicate that participation in the fellowship was associated with higher rates of membership in an academic professional association, speaking to national professional meetings, publishing in professional journals, and having research as a part of one's routine work. Program participation was also associated with higher rankings being given to research and teaching residents in contrast with physicians in a comparison group. However, all family physicians surveyed for this study reported high interest and time commitment to patient care. Results are discussed in terms of the careers of academic family physicians and faculty development programs aimed at promoting such careers.

Implementation and evaluation of a new approach to clinical instruction.

An approach to clinical instruction based on the Learning Vector model was introduced in a hospital laboratory during the 1985-86 academic year. Fifteen clinical instructors and nine medical technology students participated in the study. Clinical instructors attended an initial workshop on the model and met monthly during the academic year with the project directors to discuss their progress. The implementation of the model and the reactions of students and instructors to the model were evaluated using attitudinal questionnaires, interviews, and observations. Instructors were most successful using the model during the learning activities component of clinical instruction and were less consistent in implementing the model in the expectation-setting and evaluation components of instruction. According to instructors and students, advantages of this approach included improved communication, guidance and organization of instruction, and an increased emphasis on feedback and evaluation. The major constraint to implementation was a limited amount of time spent with students, due to scheduling or workload.

Characteristics of effective family medicine faculty development programs.

Five federally funded family medicine faculty development programs were site visited from December 1985 to June 1986 to collect from experienced project directors, staff, and faculty their thoughts on training practices and future funding. The sites selected were the Faculty Development Center of Texas in Waco (McLennan County Medical Education and Research Foundation), the National Center for Faculty Development at the University of Miami, and programs at Michigan State University, the University of North Carolina-Chapel Hill, and Duke University. Since the late 1970s these programs have trained 259 fellows and 3,284 other participants. In total, $7,515,350 in federal dollars were spent. A variety of program formats and strategies were used to recruit faculty, and to prepare them in teaching, research, and other skill areas. Interviews (as well as phone conversations and letters) with key personnel at each site resulted in a summary of 30 critical elements identified for effective faculty development. Additionally, respondents made 11 specific recommendations to the Federal Faculty Development Grant Program that concern funding and future programs.