Using standardized patients as teachers: a concurrent controlled trial.

PURPOSE: To compare two methods of teaching physical assessment, a traditional faculty-taught course and a course with components taught by specially trained standardized patients (SPs), with respect to students' performances and costs. METHOD: Medical students in their second year and without preliminary course work in physical assessment were taught by faculty-led small groups. Students in their first year were taught by faculty-led lecture-demonstrations and exercises led by physical examination teaching associates (PETAs). Both groups of students were tested with a performance-based examination that involved six identical stations. The costs of both courses were calculated using faculty and SP salaries. RESULTS: There was no difference in students' performances on two of the stations, those involving the eye and abdominal examinations. The class that had been taught by PETAs, however, demonstrated a statistically significant performance advantage on the remaining four stations. The cost saving from using the PETAs was conservatively estimated at $24,155. CONCLUSION: Specially trained SPs can effectively teach the normal physical examination to medical students and are a less expensive alternative to traditional faculty small-group teaching methods.

Impacting faculty teaching and student performance: nine years' experience with the Objective Structured Clinical Examination.

BACKGROUND: The impetus for administering the 2nd-year Objective Structured Clinical Examination (OSCE) came from the great variability in student performance observed by 3rd-year clerkship directors. PURPOSE: To document the effects of the OSCE on faculty teaching, student performance, and the curriculum over 9 years of administration of the examinations to more than 1,000 second-year medical students. METHOD: A 20-station OSCE was administered to all medical students at the end of their 2nd year. Using predetermined criteria, clinical faculty served as evaluators in each station. A mix of 1st-, 3rd-, and 4th-year medical students were recruited to serve as simulated patients. Faculty evaluators and examinees completed a questionnaire evaluating their experience with the OSCE. Students received a report card of their performance. Small-group leaders of the Introduction to Clinical Medicine course received feedback on their group's performance on each station compared to the class mean. Summative data on class performance was reported to the curriculum committee. The academic status committee received data on students who performed unsatisfactorily. RESULTS: Faculty and examinee ratings of the OSCE experience were very positive. Over the 9-year period, student performance improved showing less variability and significantly fewer failed stations. CONCLUSION: The OSCE has proven to be a technically feasible, authentic evaluation method yielding valuable information for decisions regarding student performance, faculty teaching, and curriculum planning.

Medical students' knowledge and misconceptions about aging: responses to Palmore's Facts on Aging Quizzes.

Palmore's Facts on Aging Quizzes I and II and Facts on Aging Mental Health Quiz were administered as a single test to third-year medical students before and after their 6-week Community Health and Family Medicine clerkship. The clerkship experience contributed to a small improvement in students' knowledge about the aged, net bias scores decreased from pre- to posttest, and scores on FAQI were significantly higher than scores on FAQII both pre- and posttest.

Impact of a required family medicine clerkship on medical students' attitudes about primary care.

A study of 314 medical students before and after a required third-year clerkship in family medicine explored relationships among exposure to the clerkship and changes in attitudes toward primary care. The survey instrument contained 29 statements distinguishing the philosophy of primary care from that of subspecialty-oriented medicine and asked students' to state their future residency plans. The responses of the primary care and subspecialty-oriented groups were the most disparate, whereas the students who were uncertain about residency plans shifted on several items from an alignment with the specialty group toward an alignment with the primary care group. This study shows that experience in a family medicine clerkship may be associated with changes in attitudes that represent development of a more informed image of primary care.

Jejunoileal bypass for morbid obesity. Late follow-up in 100 cases.

To evaluate the results of jejunoileal bypass for morbid obesity, we studied 100 patients with intact bypasses an average of more than five years after surgery. Mean weight loss at five years was 102.7 lb (46.6 kg) (33 per cent). Although nearly half the patients regained some weight between one and five years after surgery, only 17 per cent regained 20 lb (9 kg) or more. Medical benefits (such as improved glucose tolerance and lowered blood pressure) were maintained at five years, but side effects and complications continued to occur in the late postoperative period. Diarrhea (more than three stools per day) persisted in 58 per cent of the patients, and electrolyte disturbances occurred in over a third. Diminished levels of B12 or folate or both were present in 88 per cent. Twenty-one per cent of the patients had nephrolithiasis, and 20 per cent of those who were at risk required cholecystectomy. Progressive hepatic structural abnormalities occurred in 29 per cent of the patients, and there was a 7 per cent incidence of cirrhosis. Although 81 per cent of the patients had satisfactory results at five years, side effects and complications continued to occur, mandating careful follow-up indefinitely. The risk-to-benefit ratio at five years after surgery seems acceptable, but the continued untoward effects of the bypass in the late postoperative period have led us to abandon this procedure in favor of gastric bypass. Only continued longitudinal follow-up will determine whether on balance jejunoileal bypass represents such a serious long-term health hazard that prophylactic restoration of intestinal continuity is indicated.

Late hepatic histopathology after jejunoileal bypass for morbid obesity. Relation of abnormalities on biopsy and clinical course.

Late biopsy results in 53 patients after jejunoileal bypass were reviewed and compared with 1 year postoperative biopsies. Patients were divided into groups based on clinical course and liver function tests. Of 24 patients with normal liver function tests and no clinical symptoms of liver failure, 8 (33 percent) had new or progressive lesions on late biopsy, while 1 of these 8 patients had cirrhosis. Thirty percent (6 of 20) of patients with liver function abnormalities but no evidence of liver failure showed evidence of progression on biopsy; 4 of these 6 patients had cirrhosis. Of those with clinical evidence of liver failure in the first year after operation, 44 percent had evidence of progression, but none had cirrhosis. Clinical parameters and liver function tests did not correlate with liver biopsies. In this series of patients, new and progressive lesions were found in the late postoperative period. Long-term serial biopsies are advisable in all patients after jejunoileal bypass to determine whether progressive deterioration in liver histology had occurred.

The incidence of cholelithiasis after jejunoileal bypass.

In a prospective study of morbid obesity at the University of Florida, 225 consecutive patients with medical complication of obesity underwent intestinal bypass during a ten-year period from 1967 to 1977. The average age was 35 years, with the average weight being 322 lb (145 kg). Oral cholecystograms were obtained preoperatively in all patients, and repeated at one and five years postoperatively. If a patient developed symptoms, ultrasonography or a cholecystogram was performed at that time. The cumulative preoperative prevalence of cholelithiasis was 30.7 percent. The 156 patients with an intact gallbladder made up the study group. These patients have been followed for an average of 36 months, and 16 have subsequently demonstrated cholelithiasis. The post intestinal bypass incidence of cholelithiasis from surgery to the time of their last oral cholecystogram was 7.2 percent per year. Analysis of variance demonstrated no significant differences between patients, with and without cholelithiasis, with respect to serum triglycerides, cholesterol, or percent weight loss. The incidence of cholelithiasis in the morbidly obese increases further with the metabolic derangements induced by jejunoileal bypass. The increased incidence of cholelithiasis after intestinal bypass, along with the other serious metabolic sequelae that follow this procedure, suggests that the continued long-term followup of these patients is mandatory.

Doxycycline in the prevention of hepatic dysfunction: an evaluation of its use following jejunoileal bypass in humans.

A prospective randomized study was carried out to evaluate doxycycline hyclate in the prevention of hepatic dysfunction following jejunoileal bypass for morbid obesity. Forty-five patients were entered into the study and were observed for a year or more. Patients received either 100 mg of doxycycline hyclate twice daily on postoperative days 5 through 10 and then 100 mg daily for six weeks, or no drug. At six weeks, 12 weeks, and 12 months after the operation, biochemical levels were measured. After one year all patients had a liver biopsy. Doxycycline, in the regimen, was not demonstrated to be of value in the prevention of hepatic dysfunction in these patients. A lack of correlation was demonstrated between the biochemical definition of hepatic dysfunction and liver histopathology.