When Suicide Happens in the Medical Community.

When suicide happens close to doctors, students, and faculty, to our families, friends, colleagues, students, residents, fellows and patients, it challenges us as individuals and as members of institutions that seek to provide safety and support. The US suicide rate has increased and suicide remains difficult to predict or to prevent despite its association with depression and addiction. It is less common in medical students and residents than in the general, age-matched population but generates troubling, complex aftershocks for us. Individuals react according to their history and style, through stages, psychological defenses, and difficult affects. Grief, shock, anger, denial, and guilt are prevalent. People responding to a close suicide seek information, asking "why", "what if" and "if only", despite the speculative nature of attempting to understand what happened and why. Nearby suicide may be more challenging for us in the medical profession because the helplessness it evokes undermines our sense of omniscience and omnipotence. Thus, we engage in retrospection and a search for preventive interventions that may or may not be evidence based, salutary, or healing.

Does improving patient-practitioner communication improve clinical outcomes in patients with cardiovascular diseases? A systematic review of the evidence.

OBJECTIVE: To conduct a systematic literature review appraising the effects of interventions to improve patient-practitioner communication on cardiovascular-related clinical outcomes. METHODS: Databases were searched up to March 27, 2013 to identify eligible studies that included interventions to improve patient and/or practitioner communication skills and assessment of a cardiovascular-related clinical outcome in adults ≥18 years of age. RESULTS: Fifteen papers were reviewed: the primary focus in seven studies was the patient; seven included a practitioner-focused intervention and one targeted both. Two patient-focused and two practitioner-focused studies demonstrated a beneficial effect of the intervention compared to a control group. Patient-focused studies were designed to improve patients' information-seeking and question-asking skills with their practitioner. Practitioner-focused studies were designed to either improve practitioner's general patient-centered communication or risk communication skills. CONCLUSION: Few interventions targeting patient-practitioner communication have assessed the impact on cardiovascular-related clinical outcomes, limiting the ability to determine effectiveness. Additional rigorous research supported by theoretical frameworks and validated measurement is needed to understand the potential of patient-practitioner communication to improve cardiovascular-related clinical outcomes. PRACTICE IMPLICATIONS: Investments in communication skills trainings in medical education and practice are needed in order to attain the full potential of patient-centered care on cardiovascular-related clinical outcomes.

Training physician investigators in medicine and public health research.

OBJECTIVES: We have described and evaluated the impact of a unique fellowship program designed to train postdoctoral, physician fellows in research at the interface of medicine and public health. METHODS: We developed a rigorous curriculum in public health content and research methods and fostered linkages with research mentors and local public health agencies. Didactic training provided the foundation for fellows' mentored research initiatives, which addressed real-world challenges in advancing the health status of vulnerable urban populations. RESULTS: Two multidisciplinary cohorts (6 per cohort) completed this 2-year degree-granting program and engaged in diverse public health research initiatives on topics such as improving pediatric care outcomes through health literacy interventions, reducing hospital readmission rates among urban poor with multiple comorbidities, increasing cancer screening uptake, and broadening the reach of addiction screening and intervention. The majority of fellows (10/12) published their fellowship work and currently have a career focused in public health-related research or practice (9/12). CONCLUSIONS: A fellowship training program can prepare physician investigators for research careers that bridge the divide between medicine and public health.

Two decades of Title VII support of a primary care residency: process and outcomes.

PURPOSE: To assess 23 years of Health Resources and Services Administration (HRSA) Title VII Training in Primary Care Medicine and Dentistry funding to the New York University School of Medicine/Bellevue Primary Care Internal Medicine Residency Program. The program, begun in 1983 within a traditional, inner-city, subspecialty-oriented internal medicine program, evolved into a crucible of systematic innovation, catalyzed and made feasible by initiatives funded by the HRSA. The curriculum stressed three pillars of generalism: psychosocial medicine, clinical epidemiology, and health policy. It developed tight, objectives-driven, effective, nonmedical specialty blocks and five weekly primary care activities that created a paradigm-driven, community-based, role-modeling matrix. Innovation was built in. Every block and activity was evaluated immediately and in an annual, program-wide retreat. Evaluation evolved from behavioral checklists of taped interviews to performance-based, systematic, annual objective structured clinical examinations. METHOD: The authors reviewed eight grant proposals, project reports, and curriculum and program evaluations. They also quantitatively and qualitatively surveyed the 122 reachable graduates from the first 20 graduating classes of the program. RESULTS: Analysis of program documents revealed recurring emphases on the use of proven educational models, strategic innovation, and assessment and evaluation to design and refine the program. There were 104 respondents (85%) to the survey. A total of 87% of the graduates practice as primary care physicians, 83% teach, and 90% work with the underserved; 54% do research, 36% actively advocate on health issues for their patients, programs, and other constituencies, and 30% publish. Graduates cited work in the community and faculty excitement and energy as essential elements of the program's impact; overall, graduates reported high personal and career satisfaction and low burnout. CONCLUSIONS: With HRSA support, a focused, innovative program evolved which has already met each of the six recommendations for future innovation of the Alliance for Academic Internal Medicine Education Redesign Task Force. This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Using Bedside Rounds to Teach Communication Skills in the Internal Medicine Clerkship.

BACKGROUND: Physicians' communication skills, which are linked to important patient outcomes, are rarely explicitly taught during the clinical years of medical school. This paper describes the development, implementation, and evaluation of a communication skills curriculum during the third-year Internal Medicine Clerkship. METHODS: In four two-hour structured bedside rounds with trained Internal Medicine faculty facilitators, students learned core communication skills in the context of common challenging clinical situations. In an end-of-clerkship survey students evaluated the curriculum's educational effectiveness. RESULTS: Over the course of a year, 160 third-year students and 15 faculty participated. Of the 75/160 (47%) of students who completed the post-clerkship survey, almost all reported improvement in their communication skills and their ability to deal with specific communication challenges. CONCLUSIONS: The curriculum appears to be a successful way to reinforce core communication skills and practice common challenging situations students encounter during the Internal Medicine Clerkship.

"Oh! She doesn't speak English!" Assessing resident competence in managing linguistic and cultural barriers.

BACKGROUND: Residents must master complex skills to care for culturally and linguistically diverse patients. METHODS: As part of an annual 10-station, standardized patient (SP) examination, medical residents interacted with a 50-year-old reserved, Bengali-speaking woman (SP) with a positive fecal occult blood accompanied by her bilingual brother (standardized interpreter (SI)). While the resident addressed the need for a colonoscopy, the SI did not translate word for word unless directed to, questioned medical terms, and was reluctant to tell the SP frightening information. The SP/SI, faculty observers, and the resident assessed the performance. RESULTS: Seventy-six residents participated. Mean faculty ratings (9-point scale) were as follows: overall 6.0, communication 6.0, knowledge 6.3. Mean SP/SI ratings (3.1, range 1.9 to 3.9) correlated with faculty ratings (overall r=.719, communication r=.639, knowledge r=.457, all P<.01). Internal reliability as measured by Cronbach's alpha coefficients for the 20 item instrument was 0.91. Poor performance on this station was associated with poor performance on other stations. Eighty-nine percent of residents stated that the educational value was moderate to high. CONCLUSION: We reliably assessed residents communication skills conducting a common clinical task across a significant language barrier. This medical education innovation provides the first steps to measuring interpreter facilitated skills in residency training.

Teaching the psychosocial aspects of care in the clinical setting: practical recommendations.

Communication skills and the psychosocial dimensions of patient care are increasingly taught in medical schools and generalist residency programs. Evidence suggests they are not reinforced or optimally implemented in clinical training. The authors present the product of an iterative process that was part of a national faculty development program and involved both experts and generalist teachers concerning teaching psychosocial medicine while precepting medical students and residents in clinical settings. Using scientific evidence, educational theory, and experience, the authors developed recommendations, presented them in workshops, and revised them based on input from other experts and teachers, who gave feedback and added suggestions. The results are practical, expert consensus recommendations for clinical preceptors on how to teach and reinforce learning in this area. General skills to use in preparing the trainee for improved psychosocial care are organized into the mnemonic "CAARE MORE": Connect personally with the trainee; Ask psychosocial questions and Assess the trainee's knowledge/attitudes/skills/behaviors; Role model desired attitudes/skills/behaviors; create a safe, supportive, enjoyable learning Environment; formulate specific Management strategies regarding psychosocial issues; Observe the trainee's affect and behavior; Reflect and provide feedback on doctor-patient and preceptor-trainee interactions; and provide Educational resources and best Evidence. The preceptor-trainee teaching skills that are recommended parallel good doctor-patient interaction skills. They can be used during both preceptor-trainee and preceptor-trainee-patient encounters. Important common psychosocial situations that need to be managed in patients include substance abuse, depression, anxiety, somatoform disorder, physical and sexual abuse, and posttraumatic stress disorder. For these problems, where high-level evidence exists, specific psychosocial questions for screening and case finding are provided.

Teaching communication in clinical clerkships: models from the macy initiative in health communications.

Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination. In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.

Measuring the competence of residents as teachers.

Medical residents, frontline clinical educators, must be competent teachers. Typically, resident teaching competence is not assessed through any other means than gleaning learner's comments. We developed, evaluated, and integrated into our annual objective structured clinical examination a resident teaching skills assessment using "standardized" students. Faculty observers rated residents using a customized 19-item rating instrument developed to assess teaching competencies that were identified and defined as part of our project. This was feasible, acceptable, and valuable to all 65 residents, 8 students, and 16 faculty who participated. Teaching scenarios have potential as reliable, valid, and practical measures of resident teaching skills.

A year of mentoring in academic medicine: case report and qualitative analysis of fifteen hours of meetings between a junior and senior faculty member.

We describe a specific mentoring approach in an academic general internal medicine setting by audiotaping and transcribing all mentoring sessions in the year. In advance, the mentor recorded his model. During the year, the mentee kept a process journal. Qualitative analysis revealed development of an intimate relationship based on empathy, trust, and honesty. The mentor's model was explicitly intended to develop independence, initiative, improved thinking, skills, and self-reflection. The mentor's methods included extensive and varied use of questioning, active listening, standard setting, and frequent feedback. During the mentoring, the mentee evolved as a teacher, enhanced the creativity in his teaching, and matured as a person. Specific accomplishments included a national workshop on professional writing, an innovative approach to inpatient attending, a new teaching skills curriculum for a residency program, and this study. A mentoring model stressing safety, intimacy, honesty, setting of high standards, praxis, and detailed planning and feedback was associated with mentee excitement, personal and professional growth and development, concrete accomplishments, and a commitment to teaching.

Medical humanities at New York University School of Medicine: an array of rich programs in diverse settings.

The New York University School of Medicine has a rich tradition of cultivating programs in medical humanities and professionalism. They are drawn from the departments, centers, students, and faculty in the School of Medicine, have linkages throughout the university, and are interwoven into the fabric and culture of the institution. Some are centrally based in the School of Medicine's deans' office, and others are located in individual departments and receive support from the dean's office. This article describes representative programs for medical students and faculty. Curricular initiatives, the fundamental components of medical students' learning, include a course entitled "The Physician, Patient, and Society," a clerkship essay in the Medicine Clerkship, an opportunity for reflection during the medicine clerkship, and a medical humanities elective. In 2002, the Professionalism Initiative was launched to enhance and reflect the values of the medical profession. Its curriculum consists of a series of events that coordinate, particularly, with existing elements of the first-year curriculum (e.g., orientation week, a session during anatomy, a self-assessment workshop, and a peer-assessment workshop). The Master Scholars Program is a group of five, theme-based master societies consisting of faculty and students who share common interests around the society's themes. Programs developed for the societies include colloquia, faculty-led seminars, a mandatory student-mentoring program, and visiting scholars. Finally, the authors describe three high-quality literary publications created at New York University School of Medicine. Each of the initiatives undergoes regular critical examination and reflection that drive future planning.

Effect of communications training on medical student performance.

CONTEXT: Although physicians' communication skills have been found to be related to clinical outcomes and patient satisfaction, teaching of communication skills has not been fully integrated into many medical school curricula or adequately evaluated with large-scale controlled trials. OBJECTIVE: To determine whether communications training for medical students improves specific competencies known to affect outcomes of care. DESIGN AND SETTING: A communications curriculum instituted in 2000-2001 at 3 US medical schools was evaluated with objective structured clinical examinations (OSCEs). The same OSCEs were administered to a comparison cohort of students in the year before the intervention. PARTICIPANTS: One hundred thirty-eight randomly selected medical students (38% of eligible students) in the comparison cohort, tested at the beginning and end of their third year (1999-2000), and 155 students in the intervention cohort (42% of eligible students), tested at the beginning and end of their third year (2000-2001). INTERVENTION: Comprehensive communications curricula were developed at each school using an established educational model for teaching and practicing core communication skills and engaging students in self-reflection on their performance. Communications teaching was integrated with clinical material during the third year, required clerkships, and was supported by formal faculty development. MAIN OUTCOME MEASURES: Standardized patients assessed student performance in OSCEs on 21 skills related to 5 key patient care tasks: relationship development and maintenance, patient assessment, education and counseling, negotiation and shared decision making, and organization and time management. Scores were calculated as percentage of maximum possible performance. RESULTS: Adjusting for baseline differences, students exposed to the intervention significantly outperformed those in the comparison cohort on the overall OSCE (65.4% vs 60.4%; 5.1% difference; 95% confidence interval [CI], 3.9%-6.3%; P<.001), relationship development and maintenance (5.3% difference; 95% CI, 3.8%-6.7%; P<.001), organization and time management (1.8% difference; 95% CI, 1.0%-2.7%; P<.001), and subsets of cases addressing patient assessment (6.7% difference; 95% CI, 5.9%-7.8%; P<.001) and negotiation and shared decision making (5.7% difference; 95% CI, 4.5%-6.9%; P<.001). Similar effects were found at each of the 3 schools, though they differed in magnitude. CONCLUSIONS: Communications curricula using an established educational model significantly improved third-year students' overall communications competence as well as their skills in relationship building, organization and time management, patient assessment, and negotiation and shared decision making-tasks that are important to positive patient outcomes. Improvements were observed at each of the 3 schools despite adaptation of the intervention to the local curriculum and culture.

Reflections on integrating theories of adult education into a medical school faculty development course.

The purpose of this study was to test a three-day course model for medical school faculty designed to promote self-directed learning, teaching skills, personal awareness and interdisciplinary collegiality. The training program described was conducted three times in our medical school. Fifty-eight faculty from 11 clinical departments have participated in this intensive experience of learning how to teach, based on principles of learner-centered learning and adult education theory. Participants defined their own learning objectives and worked collaboratively in facilitated small groups to develop teaching skills. Reflection groups engaged in discussion on critical incidents of experience as teachers and learners, and promoted awareness regarding personal approaches to teaching. Qualitative and quantitative data showed that the course was effective in: (1) providing an academically and emotionally safe environment for learning; (2) enabling participants to recognize and value learner-centered learning; (3) increasing participant personal awareness, and (4) promoting interdisciplinary collegiality. End-of-course data assessing the following course attributes, using a five-point scale, where 1 was 'not effective' and 5 was 'very effective', showed: (a) exploration of needs: mean 4.20 +/- SD 0.91; (b) interactive sharing of ideas; mean 4.60 +/- SD 0.58; (c) opportunity to receive feedback: mean 4.26 +/- SD 0.80; (d) opportunity to practice new skills; mean 4.11 +/- SD 0.72. In terms of participation in further faculty development, 92% of participants committed themselves to continue the work begun at the course. It was concluded that the faculty development program created a safe, learner-centered environment for participants that promoted both awareness of and commitment to self-directed learning, and facilitated teaching skill development and interdisciplinary collegiality. Our three-day course appears to be highly effective in initiating a long-term faculty development process. Additionally, we conclude that there is a need for longitudinal follow-up to support and expand mastery of these teaching skills.