Reinforcement of occupational history taking: a success story.

BACKGROUND: This article describes the results of a retrospective study of 3 classes of medical students who participated in a targeted occupational and environmental health curriculum at the University of Connecticut School of Medicine. PURPOSE: We wanted to determine if targeted focused curricular interventions which integrated occupational and environmental health principles into routine history taking would result in increased scores on the number of questions posed during the Clinical Skills Assessment Program in the 4th year. METHODS: We analyzed Clinical Skills Assessment Program questions for 3 graduating medical school classes from 1997 to 1999. RESULTS: It appears that intense, focused training may increase the occupational and environmental questions which students ask. By revisiting the components of the history during the 3rd year, the final assessment of 4th-year students substantially and significantly increased. CONCLUSIONS: Those who wish to stem the decline in history-taking skills as students enter their clinical years should consider reinforcing these skills using structured programs and practice in areas of the history that are traditionally neglected but recognized as essential in gathering comprehensive data on patients.

The impact of a curriculum renewal project on students' performances on a fourth-year clinical skills assessment.

PURPOSE: To study the performances of three consecutive classes of medical students on a fourth-year clinical skills assessment that remained constant during a curriculum renewal project that involved earlier clinical work, more ambulatory training, and an emphasis on lifelong learning. METHOD: Three classes were involved: 83 baseline students (class of 1997) educated in the old curriculum, 77 transitional students (class of 1998) exposed to some curricular change, and 88 renewal students (class of 1999) in the first year of full curricular change. Each class completed a fourth-year assessment, during which students performed a focused history and physical examination on 14 standardized patients. Scores for these elements were calculated as the percentages of items obtained. Each case also includes a communication skills element rated on the Arizona Clinical Interview Rating scale (ACIR). RESULTS: Small but significant improvements in the means of scores were found in all three elements of the assessment over the study period (history taking scores increased from 74% to 80%, physical exam scores increased from 51% to 58%, and ACIR scores increased from 3.7 to 4.0). More pronounced was the decline in the percentage of students who failed the assessment (from 8% to 0%), and a marked increase in those who passed over 80% of the case elements (from 65% to 89%). CONCLUSION: Renewing the curriculum to expose students to clinical skills earlier, increase the amount of ambulatory training, and promote lifelong learning resulted in small but significant increases in students' performances on a fourth-year clinical skills assessment. The major impact of the new curriculum, however, was to improve the clinical skills assessment performances of marginal and average students.

Reducing HIV/AIDS high-risk behavior among injection drug users: peers vs. education.

This study examines the effects of peer groups and education on risk behavior for HIV among injection drug users (IDUs). The sample consisted of 682 participants in the Eastern Connecticut Health Outreach project, which compares traditional and peer-driven outreach interventions for IDUs. Participants are educated about safer injecting, subsequently administered a risk-reduction knowledge test, and given an extensive interview. Logistic regression shows that education alone is not a significant factor in reducing risky behavior in IDUs among the behaviors studied. A significant interaction was found between peer support for safer use and personal saliency of peer attitudes for both syringe and water sharing. Neither peer attitudes nor education affected cooker sharing. These results suggest that while education may be an important component in any intervention, it is not alone sufficient to reduce risky behavior. Our findings suggest that peer-directed interventions may be useful in reducing some forms of risk behavior among IDUs.

Teaching patient wellness to first-year medical students: the impact on future ability to perform the history of present illness.

OBJECTIVES: Curriculum innovations to improve clinical skills have been implemented at many American medical schools. A current curricular change at the University of Connecticut School of Medicine involves teaching wellness to students in the first year rather than the more traditional focus on disease processes. It is unknown, however, if focusing on wellness detracts from students' future ability to perform the history of present illness (HPI) which requires students to focus on disease processes. DESIGN: The current study examined this issue by comparing two cohorts' clinical skills (n=156), with one class participating in a traditional curriculum during their first year and the other in a revised curriculum teaching wellness during the first year. Each class was evaluated at the beginning of their second year to determine their level of clinical competence. SETTING: University of Connecticut School of Medicine SUBJECTS: Second-year medical students. RESULTS: Analyses suggested that teaching wellness did not detract from future ability to perform an HPI, and in fact students taught wellness had significantly higher history-taking scores. CONCLUSIONS: Curricular innovations which stress wellness and prevention early in medical education do not detract from and may enhance students' ability to perform the history of present illness later during medical training.

Harnessing peer networks as an instrument for AIDS prevention: results from a peer-driven intervention.

OBJECTIVE: Since 1985, community outreach efforts to combat acquired immunodeficiency syndrome (AIDS) among injecting drug users (IDUs) in the United States have overwhelmingly depended on a provider-client model that relies on staffs of professional outreach workers. We report on a comparison of this traditional outreach model with an innovative social network model, termed "a peer-driven intervention" (PDI). The latter provides IDUs with guidance and structured incentives that permit them to play a much more active role in the outreach process, thereby harnessing peer pressure on behalf of human immunodeficiency virus (HIV) prevention efforts. METHODS: We compare the performance of a traditional outreach intervention (TOI) and a PDI that were implemented in medium-sized towns in eastern and central Connecticut. Comparisons are based on the number and representativeness of IDUs recruited at each site, the effectiveness of HIV prevention education, compliance rates with AIDS risk reduction recommendations, and relative cost. The analyses are based on 522 initial interviews and 190 six-month follow-up interviews conducted during the first two years of each intervention's operation. RESULTS: Both interventions produced significant reductions in HIV risk behaviors, as measured using self-reports. The PDI outperformed the traditional intervention with respect to the number of IDUs recruited, the ethnic and geographic representativeness of the recruits, and the effectiveness of HIV prevention education. In addition, the costs of recruiting IDUs into the intervention and educating them about HIV in the community was only one-thirtieth as much in the PDI as in the traditional intervention. CONCLUSIONS: The findings suggest that given guidance and nominal incentives, IDUs can play a more extensive role in community outreach efforts than the traditional model allows. The findings also suggest that both interventions reduce HIV-associated risk behaviors, but the PDI reaches a larger and more diverse set of IDUs, and does so at much less expense.

The rise and fall of students' skill in obtaining a medical history.

A gradual shift towards a more humanistic conception of medicine has occurred in recent years. Along with this shift have come attempts by medical educators to include interviewing and communication skills as part of the medical curriculum. The current study evaluates the effectiveness of a clinical medicine curriculum which emphasizes interviewing skills. Between 1992 and 1994 and 292 graduates of the University of Connecticut School of Medicine participated in five clinical skills teaching and assessment programmes during the four years of medical school. During each of these five programmes, the students' interviewing skills were rated using the Arizona Clinical Interview Rating Scale (ACIR). The raters were standardized patients with whom they had just completed a medical encounter. Results show that students' development of skills differed, with closure items showing the greatest increase and social history items showing the greatest decline, with an overall initial increase and then a decline in interviewing skills over the four years. Explanations for these findings include the de-emphasis of communication skills during the clinical years and the culture of medicine to which students are exposed during these years.