Teaching medical students to give bad news: does formal instruction help?

BACKGROUND: In 1994, the Oregon Health Sciences University instituted an integrated course (Principles of Clinical Medicine; PCM) of classroom and outpatient clinic experience designed to give first- and second-year medical students a head start in clinical skills. During their third year, the students have been periodically evaluated by objective structured clinical examinations (OSCEs). Part of the OSCE assesses the student's skills in giving bad news by means of role playing. Assessment criteria fall into those measuring knowledge and those evaluating humanistic skills. METHODS: To evaluate whether formal instruction in giving bad news leads to an improvement in a medical student's skills, the bad-news portions of the OSCE scores of third-year medical students taught by the old curriculum (OC) were compared with those of third-year students who had taken PCM. RESULTS: While bad news knowledge scores did not differ significantly between the two groups of students, the average bad-news humanistic score was significantly better for the PCM group (85% vs 79%; p = 0.05). There was no significant difference in average scores for either knowledge or humanistic skills between male and female students in the PCM group. The benefit of PCM regarding delivering bad news was also reflected by a survey of attending physicians who had taught students under both the old and the new curricula. The majority of those surveyed scored students' skills in related areas better after PCM. CONCLUSION: Formal instruction in the first two years of medical school improved students' humanistic skills as they relate to the delivery of bad news.

Principles of clinical medicine: Oregon Health Sciences University School of Medicine.

In 1992, the School of Medicine at Oregon Health Sciences University inaugurated a Principles of Clinical Medicine (PCM) course as part of an overall curricular revision. The PCM course, which covers the first and second years of medical school, integrates material from ten separate courses in the previous curriculum. Students learn longitudinally over the two years, rather than "cramming" discrete areas of knowledge and then moving on. Course sessions are related to concurrently taken basic science classes. Meeting two afternoons per week, the PCM course offers preceptorships, health care issues sessions, and patient examination sessions. The PCM course aims to encompass the body of knowledge, skills, and attitudes necessary to become a competent physician. First- and second-year students have more opportunities than previously to interact with patients and practicing physicians in the community. Competition between learning areas, student perceptions of "soft" and "hard" courses, teacher recruitment, and administrative burnout are ongoing difficulties, while faculty recognition and development, administrative commitment and flexibility, and student and faculty feedback all contribute to the success of the course. The PCM course is now the backbone of the first two years of medical school and creates a solid foundation for the third and fourth years.

The use and compensation of community preceptors in U.S. medical schools.

PURPOSE: To better understand how U.S. medical schools are using and compensating community preceptors. METHOD: In 1995, the authors sent questionnaires to associate deans for education at all 125 U.S. medical schools. Each questionnaire asked whether that school used community preceptors to teach students and, if so, from what disciplines community preceptors came, at what sites community preceptors taught students, how community preceptors were compensated, and how these factors varied for each year of medical school. RESULTS: One hundred schools (80%) completed the questionnaire. Ninety-six reported using community preceptors. Primary care physicians were used most often, and private practices were the dominant teaching location. A clinical academic appointment was the most common compensation. Few schools compensated community preceptors monetarily. Community preceptors' involvement was substantial in all four years, but greatest in year three. CONCLUSION: Community preceptors are widely used in educating medical students, especially in year three. More recognition and better compensation of these important educators is necessary.

Principles of clinical medicine: an interdisciplinary integrated 2-year longitudinal course.

In keeping with the Report of the Panel on the General Professional Education of the Physician (Association of American Medical Colleges 1984), Oregon Health Sciences University (OHSU) School of Medicine is in the midst of revising its curriculum. After a 4-year process, the Curriculum Committee mandated development of the Principles of Clinical Medicine course, a 2-year longitudinal course integrating input from both basic and clinical science departments. We describe the steps leading to the course's implementation, its administrative and organizational structure, the evaluation of student performance, teacher training, course curriculum, and the use of interdisciplinary teaching. This course embodies many of the changes called for in the AAMC Report and serves as a model for interdisciplinary education.

Use of a group objective structured clinical examination with first-year medical students.

PURPOSE: To evaluate the implementation of a quarterly group objective structured clinical examination (GOSCE) to assess the patient-evaluation abilities of a medical school class. METHOD: The study subjects were 94 first-year students participating in the Principles of Clinical Medicine course at the Oregon Health Sciences University School of Medicine in 1992-93. To create the GOSCE, the authors modified the format of the quarterly objective structured clinical examination by making each standardized-patient station the site of an interaction between a standardized patient and a group of four or five students. The GOSCE's reliability, content and face validity, and expense were evaluated. Student feedback was obtained using a structured questionnaire. RESULTS: Performances varied both among the five stations of the GOSCE and among the 23 student groups: the mean percentage of items performed correctly per station was 83%, with a range of 73-97%. The reliability of the GOSCE's stations was low, with intraclass correlations during the three consecutive quarters of .29, .05, and .12. Despite no prior experience with this type of testing, the students' mean rating of the GOSCE's appropriateness was 3.8 (on a Likert scale of 1, poor, to 5, excellent), compared with 2.5 for the appropriateness of the written examination also used for quarterly assessment. The expense of the GOSCE was much less than the costs reported for the OSCE format. CONCLUSION: The use of the quarterly GOSCE favorably influenced the students, faculty, and curriculum. The GOSCE format made possible the assessment of a large number of students' abilities, without the time and expense needed to evaluate students individually.

Characteristics and perceptions of nicotine patch users.

BACKGROUND: Although transdermal nicotine patches are frequently prescribed to aid in smoking cessation, little information exists about their use in general medical practice. In clinical studies, nicotine patches have been found to be effective when used in conjunction with nonpharmacologic interventions, such as physician counseling and follow-up visits. This study examines the characteristics and perceptions of patients regarding treatment with nicotine patches. METHODS: Patients filling or refilling prescriptions for a nicotine patch at 17 pharmacies were asked to complete a questionnaire. RESULTS: Seventy-six questionnaires were returned. Thirty-six percent of the respondents first learned about the nicotine patch from the media, 32% from friends, family, or co-workers, and 25% from their physicians. Most respondents (87%) had requested the patch, whereas only 9% had been asked by their prescriber to try the patch. Most of the surveyed smokers were highly motivated to quit, and 86% smoked at least one pack per day. Eighty percent indicated they had received a clear message from their physicians to quit, 56% said their physician had counseled them about relapse, and 55% had follow-up arranged. A quit date had been set by 37%, and only 24% reported the use of self-help materials. Approximately one half of smokers (54%) who had started using the patch indicated that they continued to smoke. CONCLUSIONS: Most respondents were good candidates for the nicotine patch based on how much they smoked and their motivation to quit. Direct-to-consumer advertising may have influenced many smokers to request treatment with the patch. Physicians should recognize that some persons may use the patch as a "quick fix," as very few respondents used the number of nonpharmacologic interventions that have proved useful in nicotine patch clinical trials. Physicians should follow the progress of patch users to ensure that they completely stop smoking during treatment.

Health promotion and early disease detection among medical school faculty.

BACKGROUND: Medical school faculty members influence students' health promotion beliefs by their patient care activities and personal health habits. We characterized the medical school environment by defining faculty's health promotion and early disease detection attitudes and practices. The data disclose faculty needs and suggest a new paradigm to alter medical students' health promotion beliefs and care patterns. METHODS: An observational study of all academic faculty was conducted at a medical school using self-report survey data collected with a confidential questionnaire. The survey instrument assessed faculty demographics, 27 behaviors, and 23 beliefs concerning health promotion. RESULTS: Eighty-four percent of faculty (575 of 683) responded. Although agreement was moderate to good between lifestyle beliefs and personal behaviors, the concordance between personal adherence to and beliefs concerning the recommended physical examinations and laboratory tests was only fair (kappa 0.21 to 0.40). CONCLUSION: Faculty's health promotion and disease detection beliefs and behaviors were inconsistent. Observing this discrepancy may relate to students' establishment of attitudes and practices. Modifying faculty's personal behaviors and altering the medical school environment might enhance students' commitment toward preventive care.

Failure of insulin treatment in obese patients with non-insulin-dependent diabetes mellitus.

A number of experts recommend the use of insulin for patients with non-insulin-dependent diabetes mellitus (NIDDM) who fail to respond to diet, exercise, and oral hypoglycemics, even when the patient is morbidly obese. This article describes the use of insulin in two obese patients with NIDDM whose obesity worsened following the institution of insulin therapy. In some cases the risk for increased obesity and its complications following the institution of insulin may offset the potential benefits of insulin therapy itself. There are two main drawbacks associated with insulin therapy in these patients. First, from a medical point of view, insulin has a lipogenic effect and may actually contribute to weight gain, hyperinsulinemia, and increased insulin resistance in obese patients with NIDDM. Second, from a behavioral point of view, the institution of insulin therapy may shift the patient's and physician's focus from the preferred lifestyle adjustments to the numerous details associated with insulin use and monitoring. Since weight gain and sedentary activity are themselves risk factors for coronary artery disease, the benefits of decreased blood glucose levels should be balanced against the risk of increased weight gain in these patients.

Comparative cytologic yield and quality of three Pap smear instruments.

BACKGROUND: Various sampling techniques of the cervix have established false negative rates ranging from 18% to 45%. A number of studies suggest that this false negative rate can be reduced by sampling techniques that are associated with higher yields of endocervical cells. METHOD: This study enrolled 301 women, each of whom had a Pap smear obtained using three different sampling instruments (a cervical brush, a plastic spatula, and a cotton swab) in random order. RESULTS: The cervical brush yielded a better endocervical sample than either of the other instruments (P < .001), and there was no difference between the swab and spatula. In addition, the recovery of endocervical cells increased with each additional sample taken, regardless of instrument used (P < .001), although the difference in yield between the second and third samples was not significant. CONCLUSIONS: To enhance the yield of endocervical cells in Pap smear sampling, consideration should be given to using the cervical brush routinely as a sampling instrument and to taking more than one sample per screening.

Estrogen replacement therapy for reducing cardiovascular disease.

The Council on Scientific Affairs of the California Medical Association presents the following inventory of items of progress in general and family practice. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of these items of progress in general and family practice that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on General and Family Practice of the California Medical Association, and the summaries were prepared under its direction.

Hopes and concerns of a first-year medical school class.

To assess the hopes and concerns of first-year medical students, the 1991 Oregon Health Sciences University (OHSU) Medical School class was surveyed during orientation. Using qualitative research methods, student responses were grouped into general categories. The most common 'hopes' were to provide personal care and develop relationships with patients, to attain self-fulfillment, and to enjoy the personal challenge and variety of medicine. Common 'concerns' were family issues, outside intervention into medicine, and loss of self. The hopes and concerns of this class revolve primarily around personal issues, rather than issues relating to their local community or to society. This information may be useful in student counselling and curriculum development. Further research is necessary to evaluate changes in this class's attitudes over time. The methodology of this study may be useful in the evaluation of the attitudes of subsequent first-year medical school classes at OHSU, and at other institutions.