Promotion Committees and Attending Meetings Improve Promotion Rates for Early Career Faculty.

INTRODUCTION: Academic promotion is an important goal in an academic physician's career trajectory. Understanding the factors that influence success in academic promotion is important in providing appropriate guidance and resources. METHODS: The Council of Academic Family Medicine Educational Research Alliance (CERA) conducted a large omnibus survey of family medicine department chairs. Participants were asked about recent promotion rates within their department, as well as about whether their department had a promotion committee, whether faculty regularly met with the chair regarding preparation for promotion, whether faculty had been assigned mentors, and whether faculty attended national academic meetings. RESULTS: The response rate was 54%. Most chairs were male (66.3%), White (77.9%), and aged 50 to 59 (41.3%) or 60 to 69 (42.3%) years. Attendance at professional meetings was associated with a higher rate of assistant-to-associate professor promotions. Departments with a committee to help faculty with promotions had higher rates of promotion for both assistant-to-associate and associate-to-full professor levels than departments without a committee. Promotion was not associated with assigned mentorship, support from the chair, departmental or institutional sponsorship of faculty development regarding promotion, or annual assessments of progress toward promotion. CONCLUSIONS: Attendance at professional meetings and the presence of a departmental promotions committee may be helpful factors in achieving academic promotion. An assigned mentor was not found to be a helpful factor.

The extent and methods of public health instruction in family medicine clerkships.

BACKGROUND AND OBJECTIVES: The Institute of Medicine recommends integrating public health (PH) and primary care to advance community health. The status of PH integration into family medicine clerkships (FMC) is unknown. We sought to determine the extent and methods of required PH instruction in FMC. METHODS: We used the Council of Academic Family Medicine Educational Research Alliance (CERA) survey of FMC directors. RESULTS: From 36%--59% of FMC directors responded to individual PH questions, reporting a mean of 36.3 hours (range 1--258) of PH instruction in the clerkship. The majority of PH instructional time relates to behavioral sciences, communication, and cultural competence. Forty-nine percent of PH instructional hours are experiential. Ninety percent of respondents agree that PH training is important for medical students; 67.5% of respondents agree that PH training is appropriate for the FMC. Respondents from public schools reported more PH training than respondents from private schools (43.85 ± 9.25 hours versus 21.29 ± 3.82 hours). There was no difference between hours of instruction reported by FMC directors with shorter (? 4 weeks) and longer (> 4 weeks) clerkships (40.8 ± 13.7 hours versus 33.7 ± 6.4 hours). Among respondents leaving comments, 24/36 (66.7%) cited insufficient time, 6/36 (16.7%) cited lack of funding, and others identified lack of faculty or preceptor expertise and lack of student interest as barriers to PH instruction. CONCLUSIONS: There is variability in how FMC are addressing PH instruction. Future research should qualitatively explore pedagogical methods and seek consensus on the competencies and best practices in PH instruction most suited to FMC.

An ounce of prevention: how are we managing the early assessment of residents' clinical skills?: A CERA study.

BACKGROUND AND OBJECTIVES: Clinical skills deficits in residents are common but when identified early can result in decreased cost, faculty time, and stress related to remediation. There is currently no accepted best practice for early assessment of incoming residents' clinical skills. This study describes the current state of early PGY-1 clinical skills assessment in US family medicine residencies. METHODS: Eleven questions were embedded in the nationwide CERA survey to US family medicine residency directors regarding the processes, components, and barriers to early PGY-1 assessment. Responses are described, and bivariate analyses of the relationship between assessment variables and percentage of international medical graduates (IMGs), type of program, and barriers to implementation were performed using chi square testing. RESULTS: Almost four of five (78.4%) responding programs conduct formal early assessments to establish baseline clinical skills (89.6%), provide PGY-1 residents with a guide to focus their learning goals (71.6%), and less often, in response to resident performance problems (34.3%). Barriers to implementing PGY-1 early assessment programs include cost of faculty time (56.3%), cost of tools (42.1%), and time for the assessment during the PGY-1 resident's schedule (41.0%). Cost of faculty time and time for assessment from the PGY-1 resident's schedule were statistically significant major/insurmountable barriers for community-based, non-university-affiliated programs. CONCLUSIONS: Early PGY-1 assessments with locally developed tools for direct observation are commonly used in family medicine residency programs. Assessment program development should be targeted toward using existing, validated tools during the PGY-1 resident's patient care schedule.

Evaluation of a web-based family medicine case library for self-directed learning in a third-year clerkship.

BACKGROUND AND OBJECTIVES: Web-based cases are well accepted by medical students and enable faculty to deliver equivalent educational experiences to all students. A 2009 literature search revealed no study investigating student use patterns of Web-based case libraries for self-directed learning. We investigated third-year students' use of a Web-based case program for self-directed learning in a family medicine clerkship. METHODS: We analyzed Design A Case usage patterns of 210 medical students during academic year 2008--2009. We compared board score differences between these students and those from the previous 5 years who did not use Design A Case. We analyzed data from a 13-item survey, administered to a subgroup of 85 students, about the strengths, weaknesses, and acceptability of the program. RESULTS: Students completed, on average, four cases, which was beyond the requirement of three. They reported that the content was highly relevant to cases they saw in clinic. Almost 75% preferred the self-directed Web-based learning over didactics, and most (64%) felt they learned more electronically. Use of the cases was associated with equivalent Board scores versus didactic lectures. CONCLUSIONS: In our setting, self-directed learning using a Web-based case program was highly acceptable to students. Web-based cases may provide an option for family medicine educators who wish to deliver equivalent educational experiences across sites.

A validated cultural competence curriculum for US pediatric clerkships.

OBJECTIVE: A 2006 national survey of pediatric clerkship directors revealed that only 25% taught cultural competence, but 81% expressed interest in a validated cultural competence curriculum. The authors designed and evaluated a multi-modality cultural competence curriculum for pediatric clerkships including a validated cultural knowledge test. METHODS: Curriculum content included two interactive workshops, multimedia web cases, and a Cultural and Linguistic Competence Pocket Guide. Evaluation included a student satisfaction survey, a Nominal Technique Focus Group, and a validated knowledge test. The knowledge test comprised 6 case studies with 49 multiple choice items covering the curricular content. RESULTS: Of 149/160 (93%) students who completed satisfaction surveys using a 5-point Likert scale, >82% strongly agreed or agreed that the curricular intervention was a meaningful experience (93%), increased their understanding of the culture of medicine (91%), increased their knowledge of racial and ethnic disparities (89%) and core cultural issues (91%), and improved their skills in working with interpreters (90%) and cross-cultural communication (82%). Top strengths identified by a focus group (34 students) included learning about interpreters, examples of cultural practices, and raised cultural awareness. Pre- and post-knowledge test scores improved by 17% (p<.0001). After six administrations, the test achieved the target reliability of .7. CONCLUSIONS: The authors successfully designed and validated a practical cultural competence curriculum for pediatric clerkships that meets the need demonstrated in the 2006 national survey. PRACTICE IMPLICATIONS: This curriculum will enable pediatric clerkship directors to equip more graduates to provide culturally sensitive pediatric care to an increasingly diverse US population.

Do electronic health records help or hinder medical education?

Many countries worldwide are digitizing patients' medical records. What impact will these electronic health records have upon medical education? This debate examines the threats and opportunities.

First-year medical students can demonstrate EHR-specific communication skills: a control-group study.

BACKGROUND AND OBJECTIVES: Graduating medical students will universally use electronic health records (EHRs), yet a June 2007 literature search revealed no descriptions of EHR-specific communication skills curricula in US medical schools. We designed and tested methods to teach first-year medical students to optimally integrate EHRs into physician-patient communication in ambulatory encounters. METHODS: We randomly assigned 17 volunteer students to control (n=8) and intervention (n=9) groups. Both groups learned the mechanics of documenting patient histories using the EHR. Additionally, we taught the intervention group EHR-specific communications skills using guided discovery, brief didactics, and practice role plays. We compared both groups' general and EHR-specific communications skills using a standardized patient (SP) case. RESULTS: Students receiving EHR communication skills training performed significantly better than controls in six of 10 EHR communication skills. In 10 of 11 general communication skills, there were no significant differences between groups. CONCLUSIONS: First-year medical students can demonstrate EHR communication skills early in their medical training. However, in our setting, students did not spontaneously demonstrate EHR skills without instruction, and such skills did not correlate with general communication skills.

Patient-centered interviewing and student performance in a comprehensive clinical skills examination: is there an association?

OBJECTIVE: Communication skills, including patient-centered interviewing (PCI), have become a major priority for educational and licensing organizations in the United States. While patient-centered interviewing is associated with positive patient outcomes and improved diagnostic accuracy, it is unknown if an association exists between patient-centered interviewing and student performance in high-stakes clinical skills assessment (CSA) examinations. The purpose of this study was to determine if generic communication skills and patient-centered interviewing skills were associated with students' overall student performance on a multi-station clinical skills assessment (CSA) examination. METHODS: This was a cross-sectional study to assess student performance with standardized patients (SPs). We conducted a retrospective review of 30 videotaped SP encounters of Third year medical students (class of 2006) at the University of Kansas School of Medicine. We measured correlations between observed PCI scores, overall CSA scores and CSA interpersonal and communication (ICS) skills scores of student-SP encounters. RESULTS: PCI scores, as measured with the Four Habits Coding Scheme, a measurement tool of patient-centered communication, were not correlated with either overall CSA scores or ICS scores. Students' PCI scores were lower than the ICS scores (57% vs. 85% of correct items). The students performed poorly (30% mean score of correct items) in eliciting patient perspectives, compared to three other domains (Invest in the beginning, Demonstrate empathy, and Invest in end) of patient-centered interviewing. CONCLUSIONS: Our study failed to demonstrate any association between student performance and patient-centered interviewing skills (PCI) in the setting of a comprehensive in-house CSA examination. Third-year medical students in our study did not practice some elements of patient-centered interviewing. PRACTICE IMPLICATIONS: Given the increasing importance of patient-centered communication, the high-stakes in-house clinical skills examinations may consider assessing patient-centered interviewing using a more comprehensive and valid checklist.

Electronic health records in outpatient clinics: perspectives of third year medical students.

BACKGROUND: United States academic medical centers are increasingly incorporating electronic health records (EHR) into teaching settings. We report third year medical students' attitudes towards clinical learning using the electronic health record in ambulatory primary care clinics. METHODS: In academic year 2005-06, 60 third year students were invited to complete a questionnaire after finishing the required Ambulatory Medicine/Family Medicine clerkship. The authors elicited themes for the questionnaire by asking a focus group of third year students how using the EHR had impacted their learning. Five themes emerged: organization of information, access to online resources, prompts from the EHR, personal performance (charting and presenting), and communication with patients and preceptors. The authors added a sixth theme: impact on student and patient follow-up. The authors created a 21-item questionnaire, based on these themes that used a 5-point Likert scale from "Strongly Agree" to "Strongly Disagree". The authors emailed an electronic survey link to each consenting student immediately following their clerkship experience in Ambulatory Medicine/Family Medicine. RESULTS: 33 of 53 consenting students (62%) returned completed questionnaires. Most students liked the EHR's ability to organize information, with 70% of students responding that essential information was easier to find electronically. Only 36% and 33% of students reported accessing online patient information or clinical guidelines more often when using the EHR than when using paper charts. Most students (72%) reported asking more history questions due to EHR prompts, and 39% ordered more clinical preventive services. Most students (69%) reported that the EHR improved their documentation. 39% of students responded that they received more feedback on their EHR notes compared to paper chart notes. Only 64% of students were satisfied with the doctor-patient communication with the EHR, and 48% stated they spent less time looking at the patient. CONCLUSION: Third year medical students reported generally positive attitudes towards using the EHR in the ambulatory setting. They reported receiving more feedback on their electronic charts than on paper charts. However, students reported significant concerns about the potential impact of the EHR on their ability to conduct the doctor-patient encounter.

Cultural competence teaching in U.S. pediatric clerkships in 2006.

PURPOSE: Cultural sensitivity may be especially important in the care of children, and national pediatric associations have issued policy statements promoting cultural competence in medical education. The authors conducted a national survey to investigate the current state of cultural competence teaching and learning within U.S. pediatric clerkships. METHOD: The authors surveyed 125 U.S. pediatric clerkship directors concerning the presence or absence of cultural curricula, content, teaching methods, and evaluation. Question types were multiple-choice single/best answer, checklists, five-point Likert-type scales, and free-text responses. RESULTS: Of 100 respondents (80% response rate), most agreed or strongly agreed that teaching culturally competent care is important (91%), enhances the physician/patient/family relationship (99%), and improves patient outcomes (90%). Twenty four of 98 respondents (25%) reported cultural competence teaching. The most common teaching methods were lectures (63%), experiential learning through community activities (58%), and small-group discussions (54%). Only 14 respondents reported any curricular evaluation, the commonest methods being student surveys, clinical case presentations, and standardized patient experiences. Top factors facilitating curriculum development were culturally diverse populations of patients, students, faculty, and hospital staff, and faculty interest and expertise. Top challenges included lack of protected time for program development, funding, and faculty expertise. CONCLUSIONS: Few U.S. pediatric clerkships currently provide cultural competence curricula. The authors' suggestions to promote cultural competence teaching include providing faculty development opportunities and developing and disseminating teaching materials and evaluation tools. Such dissemination is important to graduate physicians, who can provide culturally sensitive pediatric care to the changing U.S. population.

Appropriate prescribing of medications: an eight-step approach.

A systematic approach advocated by the World Health Organization can help minimize poor-quality and erroneous prescribing. This six-step approach to prescribing suggests that the physician should (1) evaluate and dearly define the patient's problem; (2) specify the therapeutic objective; (3) select the appropriate drug therapy; (4) initiate therapy with appropriate details and consider nonpharmacologic therapies; (5) give information, instructions, and warnings; and (6) evaluate therapy regularly (e.g., monitor treatment results, consider discontinuation of the drug). The authors add two additional steps: (7) consider drug cost when prescribing; and (8) use computers and other tools to reduce prescribing errors. These eight steps, along with ongoing self-directed learning, compose a systematic approach to prescribing that is efficient and practical for the family physician. Using prescribing software and having access to electronic drug references on a desktop or handheld computer can also improve the legibility and accuracy of prescriptions and help physicians avoid errors.

Teaching medical students to prioritize preventive services.

BACKGROUND: Clinicians cannot provide all recommended preventive services in a single office visit and must learn to prioritize. This skill is not overtly addressed in medical school. METHODS: We designed a workshop to teach third-year medical students to prioritize preventive services during an office visit. In a prospective controlled trial, we compared performance on a standardized patient case. RESULTS: Students performed well, but there was no significant difference between intervention and control groups' mean scores on the standardized patient encounter. CONCLUSIONS: Our brief intervention failed to increase students' scores on a standardized patient case requiring preventive services prioritization.