The use of electronic medical records: communication patterns in outpatient encounters.

OBJECTIVE: To assess physician-patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. DESIGN: An exploratory, observational study involving analysis of videotaped physician-patient encounters, questionnaires, and medical-record reviews. SETTING: General internal medicine practice at an academic medical center. PARTICIPANTS: Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). MAIN OUTCOME MEASURES: Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. RESULTS: Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patient's agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patient's life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. SUMMARY: An EMR system may enhance the ability of physicians to complete information-intensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified.

Use of learning contracts in an office-based primary care clerkship.

OBJECTIVES: This paper describes implementation of the learner-centred learning goal within the primary care clerkship at a Midwestern, United States medical school. DESIGN: The learner-centred learning goal exercise was developed to tailor students' educational activities to their personal level of development and to enhance their commitment to life-long learning in medicine. In the learner-centred learning goal exercise, each student records three specific learning goals early in the primary care clerkship. Students record the methods by which they will pursue and document achievement of each goal. Attainment of the learner-centred learning goal is evaluated based on an oral presentation at the end of the clerkship. We compiled presented learning goals along with the corresponding grade. Students' ratings of the learner-centred learning goal exercise were also compiled. Evaluations and ratings were made on a 1-5 Likert scale, where 1 is the best rating and 5 is worst. SETTING: Department of Medicine, Northwestern University Medical School, Chicago, USA. SUBJECTS: One hundred and seventy-seven third- and fourth-year medical students who presented learner-centred learning goals between 1 July 1995 and 30 June 1996. RESULTS: Students rated pursuing their individual learning goals more worthwhile than most clerkship lectures but less worthwhile than the office experience. Several learning goals were chosen by a disproportionate number of students, potentially indicative of some perceived deficiencies elsewhere in the curriculum. Third-year students ranked the learner-centred learning goal exercise more favourably than fourth-year students (2.14 vs. 2. 51, P = 0.03). CONCLUSIONS: The learner-centred learning goal exercise is a feasible and well-received method within our primary care clerkship. Further study is required to determine whether the exercise promotes independent learning after formal medical school education is completed.

The evolution of courses in professional skills and perspectives for medical students.

A number of medical schools substantially revised their curricula in response to the GPEP Report, issued by the Association of American Medical Colleges in 1984. One of the most important areas of change has been in the way students are introduced to the professional skills and perspectives they will need to practice clinical medicine. A number of schools have recently developed interdisciplinary courses to accomplish this goal. Such courses may differ in scheduling, format, and focus, but they share a commitment to broadening skills and perspectives through experiential learning and small-group work. Most of these courses span the entire first two years of the curriculum, and some extend into the third and fourth years, blurring the line between the "preclinical" and "clinical" years. The near-simultaneous, largely independent introduction of major courses of this type into the curricula of some medical schools has gone largely unreported in the literature. This overview article discusses the origins of these courses and reviews the scope of the curricula now in place. Among the most comprehensive programs are those at Northwestern University, Oregon Health Sciences University, the University of California, Los Angeles, and the University of Nebraska, each of which is described and discussed in the following papers.

Patient, physician & society: Northwestern University Medical School.

Northwestern University Medical School's Patient, Physician & Society (PPS) course was introduced in 1993 as part of a complete restructuring of the first- and second-year curriculum. The PPS course meets two afternoons per week throughout the first two years, with one afternoon focusing on the relationship between patients and physicians and the other on that between physicians and society. The course is designed to provide a comprehensive, integrated introduction to professional skills and perspectives. Fourteen distinct curricular units address personal and professional ethics, medical humanities, behavioral sciences, physician-patient communication, physical diagnosis and clinical reasoning, health services organization and financing, preventive medicine, and the health of vulnerable groups. Health promotion as a primary goal of medicine is an underlying theme throughout the course. Active and interactive learning formats afford many opportunities for personal reflection and discussion. The overall response to the course has been positive, and survey data indicate that students completing PPS report more progress toward the school's fundamental educational goals than do students who had progressed through the first two years before the new curriculum was introduced. Still, a number of students are clearly uncomfortable with educational strategies that give them responsibility for finding answers on their own. Contrasts between PPS and the basic science courses--in content, presentation, and evaluation--highlight the importance of coordinating and integrating the overall medical school curriculum. Plans for enhancing the course include focusing on faculty development and student evaluation, as well as explicitly extending PPS material into the clerkship years.

The future of medical school courses in professional skills and perspectives.

This article looks toward the future of medical school courses in professional skills and perspectives by addressing the extent to which they are a valid model for educating physicians of the 21st century, highlighting what medical educators can learn from the experiences at a sample of four medical schools, and suggesting ways to strengthen this curricular genre. Each of the four courses described in this special feature strives to provide exposure and experience in behavioral science, medical ethics, physician-patient communication, health promotion and disease prevention, physical examination, clinical reasoning, and health services and financing. It is likely that students who will be practicing medicine in the 21st century would also benefit from more attention to personal awareness and professional growth. Several lessons can be drawn from the experiences with these courses: although complex, they are directed by very small groups of faculty; they require large numbers of teaching faculty; it is difficult to establish equal footing with basic science courses; evaluation of students' progress is a major challenge; it is important to clearly articulate course components; the emphasis must extend beyond the first two years; and ongoing student and faculty input is essential. The authors suggest that conducting outcome assessments, creating a more humane culture of medical education, and supporting course faculty are key to a stable future for these courses and a solid education for the students.

"Sympathy for my body": breast cancer and mammography at two Atlanta clinics.

This article examines beliefs about breast cancer and mammograms among low-income urban black women. Our research indicates that women associate breast cancer with domestic violence, believing that bruises resulting from physical abuse which is not reported or given medical attention can later turn into cancer. Some women fear that in "mashing" the breast, mammograms cause "knots" or bruises that can become cancerous. Mothers and daughters were found to have extensive knowledge of, and sense of responsibility for, each other's health. This bond can be used to encourage use of cancer screening procedures. While women assert that one's health is ultimately in God's hands, their faith appears to motivate health-seeking behavior rather than promote a fatalistic or passive orientation.

An active-learning approach to basic clinical skills.

Within the context of comprehensive changes in the preclinical curriculum at Northwestern University Medical School, the authors sought to create an active-learning approach to teaching the basic clinical skills of communication, physical examination, and diagnostic reasoning. This approach is built upon the premise that repetitive practice using a structured database, which is emphasized in traditional curricula, is necessary but not sufficient for students' early development as clinicians, as it marginalizes essential areas of discourse and restricts students' understanding of the scope of the medical encounter. Accordingly, this clinical skills curriculum incorporates small-group, patient-instructor, and peer-observation formats to encourage critical thinking and reflection. The clinical skills units have been among the most popular aspects of Northwestern's new curriculum. Preliminary data suggest that the overall attitudes, knowledge, and clinical proficiency of students completing this curriculum compare favorably with those of students who progressed through the preclinical curriculum before the active-learning approach was introduced.

First-year residents' caring, medical knowledge, and clinical judgment in relation to laboratory utilization.

PURPOSE: To investigate first-year residents' levels of caring (concern for others' well-being), medical knowledge, and clinical judgment in relation to their levels of laboratory utilization. METHOD: Self-report questionnaires about caring, knowledge, and judgment were given in 1986-87 to 36 first-year residents in a three-year internal medicine residency program of the McGaw Medical Center of Northwestern University. Inpatient laboratory utilization data obtained from structured chart audits over a one-year period were used to construct comparable diagnosis- and severity-specific physician practice profiles, from which the residents received overall utilization scores for laboratory test charges. Statistical methods included Cronbach's alpha reliability coefficient and multiple regression analysis. RESULTS: The multiple regression analysis showed that medical knowledge was an independent predictor of increased laboratory utilization (standardized beta = .54, p < .04, partial R2 = .07); clinical judgment was an independent predictor of decreased utilization (standardized beta = -.53, p < .05, partial R2 = .06); and caring was unrelated to utilization (standardized beta = .15, ns, partial R2 = .01). CONCLUSION: The finding that clinical judgment was related to less laboratory utilization suggests that future research should investigate the decision-making concomitants of judgment to better understand its translation into resource utilization. It is possible that the relationship between medical knowledge and laboratory utilization is developmentally specific, and thus the knowledge of more experienced physicians, who would likely be more precise decision makers than first-year residents, may be related to decreased rather than increased utilization.

Explanatory models for cancer among African-American women at two Atlanta neighborhood health centers: the implications for a cancer screening program.

This paper examines cultural models for breast and cervical cancer among low-income African-American women over 40, in order to better understand how those models might affect cancer screening behavior. The study is part of The Community-Based Cancer Screening Project, which is sponsored by Emory University, Grady Memorial Hospital, and the American Cancer Society. The Screening Project attempts to increase the use of mammography, clinical and self-examination of the breast, and cervical Pap smear among women aged 40 or older in a predominantly African-American, low-income, low educational level population that is currently underserved by any screening activities. The study of cultural models of cancer within the project was prompted by the recognition that if screening programs targeted at specific, underserved, populations are to succeed, cultural as well as logistical barriers to screening must be overcome. Patients and clinicians must each understand how the other perceives cancer, its prevention, and its treatment. Only with this mutual understanding as a foundation, can physicians and their clients cooperate to improve cancer screening rates. Our research results indicate that the cancer models held by the patient population differ significantly from those held by clinicians. Women attending the clinics endure cancer screening tests that to them seem to serve only as heralds of a disease that will ultimately kill them. Most women doubt there is a cure for cancer, though some believe a person may live if the disease is caught in time.(ABSTRACT TRUNCATED AT 250 WORDS)

Community-directed cancer screening program.

The Atlanta Project, one of six American Cancer Society demonstration projects, is a community-designed and -directed breast and cervical cancer screening program focused on empowering African-American women to accept responsibility for their health maintenance. This article reports the project's goals, objectives, intervention strategies, roles of key project personnel, and outcomes. A total of 3852 women older than 40 years received breast clinical examinations, were taught breast self-examination, and had a screening mammogram; 2689 women obtained a pelvic examination and were screened for cervical cancer with a Papanicolaou smear. Of those women screened, 12 breast and 1 cervical cancers were identified and treated. Important lessons learned and successes achieved from this project were: (1) there is a need for joint planning with community representatives and their involvement in all aspects of the program's implementation and evaluation; (2) in addition to the commitment of the major participants, the community must "buy in" to the proposed health intervention; (3) the focus of the intervention should be on positive health messages; (4) cancer education materials should be culturally and literacy-appropriate; (5) the project's activities were planned to be sustained after the project period; (6) women can be empowered to accept responsibility for and control over their health.

Public hospitals and managed care.

Managed health care is used increasingly in the public and private sectors to control rising health-care costs and to assure quality of care. While current proposals for health-care reform promote even wider application of managed care as a component in cost control, the formal use of managed care by public hospitals has not been fully explored. This article identifies possible reasons for providing managed care within a public-hospital system, explores the implications of managed care for public hospitals and their patients, and addresses some of the barriers to implementing managed care in a traditional public-hospital setting.

Psychological androgyny and preference in loss-framed gambles of medical students: possible implications for resource utilization.

Physician decisions concerning allocation of health care resources to patients are highly variable and poorly understood. Psychological androgyny theory (PAT) has been employed as a model of the interpersonal and task activities required of physicians for care of their patients. Several studies have successfully predicted physician resource utilization using measures derived from PAT. Using a sample of 97 first-year medical students, the authors explored the relationship between PAT and risk preference in loss-framed gambles in order to elucidate the process whereby variables derived from PAT predict resource utilization. As hypothesized, students selecting the certain loss had significantly higher mean androgyny scores than did students selecting uncertainty. Research involving these constructs is integrated in the context of a theoretical "causal model," which highlights issues deserving of future research.

U.S. residency directors' views of the importances of seven roles that pediatrics residents should master.

Pediatrics residency programs should define and evaluate for their residents and faculty the competencies that residents should acquire during their three years of training. This 1987 survey of 129 pediatrics residency directors sought data about the demographic characteristics of the programs and asked the program directors to what degree they agreed that seven roles (each comprising several competencies) of the general and ambulatory-care pediatrician were essential. There was strong agreement on the seven roles and no demonstrated association between these responses and the residency programs' university affiliations, types of facilities, ages, lengths of training, or geographic locations. The results of this survey may be useful in developing ways to document and evaluate residents' performances and define subspecialty objectives that are consistent with the seven basic roles.

Technology assessment and the evaluation of implanted medical devices.

Technology assessment is attracting new attention and funding as concern about costs and effectiveness of health care grows. This article provides a general overview of technology assessment and relates recent trends and future prospects specifically to the use and evaluation of implanted medical devices. In the next decade we may expect to see renewed interest in technology assessment as pressure to control health care costs continues and as a different focus of evaluation emerges that emphasizes patient preferences and quality of life in addition to traditional measures of safety, efficacy, and cost-effectiveness. These pressures and forces will act to increase the visibility and importance of proper assessment of medical technology, and the field may more nearly achieve its early promise as a tool to make medical care more rational.

Psychological androgyny and preference for intubation in a hypothetical case of end-stage lung disease.

Psychological androgyny theory (PAT) was employed as a model of the interpersonal (social) and task activities required of physicians for care of their patients. According to PAT, individuals with a large repertoire of task and social skills ("androgynous" individuals) should be optimally adaptable to contingencies reflecting varying combinations of task and social challenges. The authors examined the relationship between androgyny and preference for intubation on a patient management problem involving end-stage lung disease for 67 general internists and internal medicine housestaff from two hospitals. Results revealed a negative relationship between androgyny and preference for intubation, suggesting that androgynous and nonandrogynous physicians respond differently to complex and difficult decision-making tasks. Indirect evidence is offered to suggest that this response reflects a general tendency to utilize fewer health care resources. Discussion focuses on the need to improve the precision of measurement of these latent constructs.