Evaluation of a Pilot Wellness Elective for Master of Public Health Students during the COVID-19 Pandemic.

BACKGROUND: Graduate student wellbeing is a public health issue in the United States. The COVID-19 outbreak exacerbated the mental health burden on graduate students worldwide. Culture of Wellness (PH 104) is a 2-week wellbeing elective course that teaches evidence-based wellbeing strategies for graduate students at a university in the United States. Our study aimed to evaluate the impact of this pilot wellbeing elective on Master of Public Health students' mental health and wellness during the COVID-19 pandemic. METHODS: Participants included 22 Master of Public Health students from the class of 2021 at a university in the United States. We provided a pre-course survey to students that assessed their perception of their own personal wellbeing, their knowledge about various wellbeing strategies, and their confidence in applying 13 wellbeing strategies before taking the course. Post-course students completed the same survey following course completion, as well as a matching evaluation and a five-month follow up survey. RESULTS: Of the 13 strategies taught, students reported significant improvements in their ability to apply 10 strategies. There was a significant increase in self-reported emotional and physical wellbeing, as well as a significant decrease in burnout. Five months post-course, more than three quarters of respondents used strategies taught in the course on a weekly basis or more. LIMITATIONS: This pilot study is limited by its small sample size, which may restrict the generalizability of the findings. CONCLUSIONS: The PH 104 Culture of Wellness course was effective in improving graduate students' wellbeing and confidence in applying wellbeing strategies.

A Curriculum to Promote a Culture of Wellness Among Medical Students and Faculty.

INTRODUCTION: Self-care has not been traditionally taught in medical education, but the epidemic of burnout among health professionals necessitates a change in culture, and consequently a change in curriculum. Burnout begins early in training and negatively impacts health professionals, patients, and institutions. Interventions that prevent and avert burnout are necessary at all stages of a doctor's career to assure well-being over a lifetime. Evidence-based strategies supporting both personal and system wellness have begun to emerge, but more research is needed. METHODS: We present a collaborative and comprehensive wellness program: "A Culture of Wellness." We offered this pilot jointly for first-year medical students and faculty volunteers at the Geisel School of Medicine at Dartmouth. We gave participants the following: (1) time-60 minutes per week for 8 weeks; (2) tools-weekly cases highlighting evidence-based wellness strategies; and (3) permission-opportunities to discuss and apply the strategies personally and within their community. RESULTS: Pre- and postsurvey results show that dedicated time combined with student-faculty collaboration and application of strategies was associated with significantly lower levels of burnout and perceived stress and higher levels of mindfulness and quality of life in participants. Components of the curriculum were reported by all to add value to personal well-being. CONCLUSIONS: This pilot presents a feasible and promising model that can be reproduced at other medical schools and disseminated to enhance personal health and promote a culture of well-being among medical students and faculty.

Preclinical preceptorships in medical school: can curricular objectives be met in diverse teaching settings?

BACKGROUND: Although preclinical preceptorships for medical students during the first 2 years are now common, little is known about how well the curricular objectives can be met in clinical training sites. PURPOSE: To evaluate whether a clinical encounter system can help align preclinical preceptorship experiences with the core curriculum. METHODS: Using a PDA documentation system, 27 students collected student-preceptor-patient encounter information on all patients (N = 2,953) during a 2-year clinical training course. We compared Years 1 and 2 teaching and learning processes, common symptoms seen, and counseling skills performed and examined how well these clinical experiences aligned with the curricular goals. RESULTS: The majority of encounters in Year 1 involved the student observing the preceptor perform a history (47%) or physical exam (40%). In Year 2, there was a shift to student and preceptor both participating in the history (Year 1, 12%; Year 2, 24%; p = .004) and physical exam (Year 1, 34%; Year 2, 47%; p = .002). Cardiovascular; pulmonary; and head, eyes, ears, nose, and throat examinations were most common in Year 1 and increased in Year 2. Genitourinary, gynecologic, and neurological examinations occurred least often, and only the neurological examinations increased significantly in Year 2. Overall, at least 75% of students could find opportunities in Years 1 and 2 to achieve the majority of curricular goals. CONCLUSIONS: Knowing what students experience at their preceptor sites is vital for clinical skills course evaluation. Student-preceptor-patient encounter data should be used to complement other course evaluations to aid curriculum planning and decrease variability in student experiences.

Educational epidemiology: applying population-based design and analytic approaches to study medical education.

Conducting educational research in medical schools is challenging partly because interventional controlled research designs are difficult to apply. In addition, strict accreditation requirements and student/faculty concerns about educational inequality reduce the flexibility needed to plan and execute educational experiments. Consequently, there is a paucity of rigorous and generalizable educational research to provide an evidence-guided foundation to support educational effectiveness. "Educational epidemiology," ie, the application across the physician education continuum of observational designs (eg, cross-sectional, longitudinal, cohort, and case-control studies) and randomized experimental designs (eg, randomized controlled trials, randomized crossover designs), could revolutionize the conduct of research in medical education. Furthermore, the creation of a comprehensive national network of educational epidemiologists could enhance collaboration and the development of a strong educational research foundation.

Teaching the testicular exam: a model curriculum from "A" to "Zack".

BACKGROUND AND OBJECTIVES: The testicular exam was not explicitly taught at our medical schools before 2002. In this article, we explore different phases of curriculum development, implementation, and evaluation of a method for teaching the testicular exam. METHODS: Medical students participated in surveys and focus groups, and male patients participated in focus groups. From the results of the focus groups, we developed a comprehensive testicular exam module that includes (1) a PowerPoint lecture, (2) a video, (3) reading materials, and (4) an artificial male model ("Zack"). These materials were then incorporated into family medicine clerkships. Students and faculty have evaluated the project. RESULTS: Initially, students expressed discomfort discussing sexual issues with patients, especially those of the opposite gender, and knew little about testicular cancer. Male patients had limited knowledge of the testicular self-exam and felt that their physical exam training had not been ideal. Faculty and students agreed that a lecture on the testicular exam and practice with Zack were useful in improving their exam skills, while the video and readings were less so. CONCLUSIONS: To address curricular deficits, a self-contained module on the testicular exam has been successfully incorporated into family medicine clerkships at two different medical schools. This module is easily adaptable to other settings and institutions.

Teaching quality measurement and improvement, cost-effectiveness, and patient satisfaction in undergraduate medical education: the UME-21 experience.

BACKGROUND: The health care system in the United States is changing at an ever-increasing rate. Recent reports by the Institute of Medicine raising concerns regarding rates of medical errors and suggesting the need for reengineering of the health care delivery system have focused attention on the need for quality measurement and improvement. METHODS: We abstracted data from final written reports submitted by 18 Undergraduate Medical Education for the 21st Century (UME-21) schools, as well as other materials available from participating UME-21 schools. Specific curricular innovations developed and implemented were identified. Additionally, senior medical students' responses to the annual Graduation Questionnaire administered by the Association of American Medical Colleges (AAMC) were available for analysis. The change from 1999 to 2001 in the proportion of seniors rating instruction in quality assurance as adequate was compared among four groups of UME-21 schools and the other 107 US medical schools. RESULTS: Eleven of the 18 schools specifically addressed the content areas of quality measurement and improvement, including utilization management (27% of schools), cost-effectiveness (45% of schools), use of clinical practice guidelines (73% of schools), and patient satisfaction assessment (45% of schools). Each school developed unique approaches and educational materials pertinent to the content area. Overall, the percentage of seniors rating the relative amount of instructional time devoted to quality assurance in medicine by their school's curriculum as adequate or better rose from 49% to 66% between 1999 and 2001 at the 11 UME-21 schools that introduced initiatives in quality improvement into their curricula. This change was significantly higher than the pattern at other US medical schools between 1999 and 2001, at which seniors' ratings rose only from 43% to 56%. CONCLUSIONS: Curriculum development and implementation addressing quality improvement in medical practice accelerate improvement of students' perception that their education has adequately addressed this subject area. This article summarizes some of the experiences, curricular approaches, successes, failures, and lessons learned in quality improvement by schools participating in the UME-21 project.

Teaching of medical informatics in UME-21 medical schools: best practices and useful resources.

OBJECTIVES: Information-based decision making is important to modern medical practice. This report identifies learning objectives, teaching innovations, and student outcomes for teaching medical informatics (MI) in medical schools that participated in the Undergraduate Medical Education for the 21st Century (UME-21) curriculum project. METHODS: Project reports by the UME-21 schools were analyzed, and curricular content was classified in terms of the five categories for MI literacy adapted from the Medical School Objectives Project. Student self-assessments of adequacy of exposure to MI were reviewed. RESULTS: Teaching methods included demonstrations, lectures, small-group tutorials, hands-on labs, and task-based assignments. The curriculum was taught during the first 3 years of medical school with medical librarians participating. Content examples in the five categories of medical literacy were: "Role of the Lifelong Learner" (accessing, evaluating, and using information and databases), "Role of Clinician" (obtaining patient information, using decision support), "Role of Educator/Learner/Communicator" (accessing information for patient education, student-teacher communication, studying Web-based cases, making presentations, accessing on-line course information), "Role of Researcher/Evaluator" (documenting patient encounters), and "Role of Manager" (using drug formularies and clinical guidelines). Seniors exposed to the UME-21 curriculum reported higher levels of exposure to MI than did untrained seniors 2 years earlier; however, seniors at non-UME-21 schools reported equally high levels. CONCLUSIONS: UME-21 schools developed creative materials for teaching students to use computers for learning, communication, and searching for information. Outcome measures suggest that MI has become an important curriculum topic in most medical schools.

Collaborating to integrate curriculum in primary care medical education: successes and challenges from three US medical schools.

BACKGROUND AND OBJECTIVES: Traditional medical school department-based clerkship structures can lead to redundancy and/or gaps in curriculum, inefficient administrative systems, and academic isolation for clerkship directors. This paper describes the approaches, successes, and challenges three institutions experienced when implementing an interdepartmental collaboration to create an integrated primary care clerkship experience. METHODS: Each school combined family medicine, ambulatory pediatrics, and ambulatory medicine into contiguous clerkship blocks. In all institutions, each clerkship maintained certain distinct features while the integrated aspects contained longitudinal curriculum of certain primary care topics. RESULTS: Evaluations by students demonstrated favorable responses to the new content and integrated methods of teaching, as did results of the Association of American Medical Colleges graduation survey. Faculty at each institution reported that their multidisciplinary approach has stimulated important educational collaborations, many of which require an economy of scale not often achievable within a single clerkship. These included innovative evaluation/documentation efforts; centralization of administrative tasks; enhanced recruitment, retention, and development of community-based faculty; an increase in the active core group of local and national primary care leaders; and an increase in scholarly activities. The collaborations have not occurred without challenges, primarily in the need for identifying sustainable resources for these and future collaborative educational endeavors. CONCLUSIONS: The benefits involved in developing an integrated primary care experience include expansion of curriculum content and methods, as well as enhancement of collegial support and resources to community-based and academic faculty. These integrations do, however, bring added challenges, time, and costs to traditional independent clerkships.

Ambulatory care education: how do academic medical centers, affiliated residency teaching sites, and community-based practices compare?

PURPOSE: Little is known about how different ambulatory sites compare as clinical educational settings. The authors used students' log data to compare the educational content and processes in academic medical center-based clinics (AMCs), affiliated residency teaching sites (ARTs), and local community-based practices (CBPs) at one medical school. METHOD: Students recorded their experiences with symptoms, counseling, procedures, and common medical conditions as well as characteristics of the learning process during a required eight-week third-year ambulatory clerkship in family medicine. Descriptive statistics, chi-square for differences in categorical variables, and analysis of variance and multivariate analysis of variance for differences in continuous variables were used to compare the educational settings. RESULTS: Over 9,000 encounters were analyzed; 29.7% occurred in AMCs, 14.8% in ARTs, and 55.5% in CBPs. The proportion of continuity visits was lowest in the AMCs and highest in CBPs (13% versus 22%, respectively; p <.01). Students saw almost 57,000 symptoms and conditions. Of 19 symptoms compared, seven differed significantly among the three settings: back pain, cough, dyspnea, ENT (ears, nose, throat problems), fatigue, knee pain, and vomiting. All but one of these were least likely to occur in ARTs. Procedures were performed more frequently, whereas counseling skills were called upon less frequently in CBPs. Students reported being more likely to work unobserved while conducting physical examinations in ARTs and CBPs. Amount of feedback provided on clinical skills did not differ, but students reported receiving more teaching about patient management in ARTs and AMCs versus CBPs (74%, 72%, and 66% of encounters, respectively; p <.01). CONCLUSIONS: Academic and community settings can complement each other as learning sites for an ambulatory clerkship in family medicine, and common curricular expectations can be achieved. Settings' differences and similarities should be taken into account when developing, implementing, or revising clerkship programs and should be considered with students' interests and previous clinical experiences before assigning students to a teaching site.

Development of a handheld computer documentation system to enhance an integrated primary care clerkship.

Documentation systems are used by medical schools and residency programs to record the clinical experiences of their learners. The authors developed a system for their school's (Dartmouth's) multidisciplinary primary care clerkship (family medicine, internal medicine, pediatrics) that documents students' clinical and educational experiences and provides feedback designed to enhance clinical training utilizing a timely data-reporting system. The five critical components of the system are (1) a valid, reliable and feasible data-collection instrument; (2) orientation of and ongoing support for student and faculty users; (3) generation and distribution of timely feedback reports to students, preceptors, and clerkship directors; (4) adequate financial and technical support; and (5) a database design that allows for overall evaluation of educational outcomes. The system, whose development began in 1997, generated and distributed approximately 150 peer-comparison reports of clinical teaching experiences to students, preceptors, and course directors during 2001, in formats that are easy to interpret and use to individualize learning. The authors present report formats and annual cost estimate comparisons of paper- and computer-based system development and maintenance, which range from $35,935 to $53,780 for the paper-based system and from $46,820 to $109,308 for the computer-based system. They mention ongoing challenges in components of the system. They conclude that a comprehensive documentation and feedback system provides an essential infrastructure for the evaluation and enhancement of community-based teaching and learning in primary care ambulatory clerkships, whether separate or integrated.

A collaborative model for supporting community-based interdisciplinary education.

Development and support of community-based, interdisciplinary ambulatory medical education has achieved high priority due to on-site capacity and the unique educational experiences community sites contribute to the educational program. The authors describe the collaborative model their school developed and implemented in 2000 to integrate institution- and community-based interdisciplinary education through a centralized office, the strengths and challenges faced in applying it, the educational outcomes that are being tracked to evaluate its effectiveness, and estimates of funds needed to ensure its success. Core funding of $180,000 is available annually for a centralized office, the keystone of the model described here. With this funding, the office has (1) addressed recruitment, retention, and quality of educators for UME; (2) promoted innovation in education, evaluation, and research; (3) supported development of a comprehensive curriculum for medical school education; and (4) monitored the effectiveness of community-based education programs by tracking product yield and cost estimates needed to generate these programs. The model's Teaching and Learning Database contains information about more than 1,500 educational placements at 165 ambulatory teaching sites (80% in northern New England) involving 320 active preceptors. The centralized office facilitated 36 site visits, 22% of which were interdisciplinary, involving 122 preceptors. A total of 98 follow-up requests by community-based preceptors were fulfilled in 2000. The current submission-to-funding ratio for educational grants is 56%. Costs per educational activity have ranged from $811.50 to $1,938, with costs per preceptor ranging from $101.40 to $217.82. Cost per product (grants, manuscripts, presentations) in research and academic scholarship activities was $2,492. The model allows the medical school to balance institutional and departmental support for its educational programs, and to better position itself for the ongoing changes in the health care system.

An analysis of students' clinical experiences in an integrated primary care clerkship.

PURPOSE: Combining complementary clinical content into an integrated clerkship curriculum should enhance students' abilities to develop skills relevant to multiple disciplines, but how educational opportunities in primary care ambulatory settings complement each other is unknown. The authors conducted an observational analytic study to explore where opportunities exist to apply clinical skills during a 16-week integrated primary care clerkship (eight weeks of family medicine, four weeks of ambulatory pediatrics, and four weeks of ambulatory internal medicine). METHOD: Using handheld computers, students recorded common problems, symptoms, and diagnoses they saw. The students also recorded information about the educational process of the clerkship. Two data files were created from the database. Descriptive statistics were used to characterize the students' clerkship experiences, and ANOVA was used to evaluate differences among these blocks within the clerkship. RESULTS: Students encountered different frequencies of presenting symptoms, the majority of which occurred in pediatrics (23.2 per student per week versus 16.3 in medicine and 16.8 in family medicine; p =.01). Students provided more behavioral change counseling in family medicine (5.2 episodes per student per week versus 4.2 and 2.0 in internal medicine and pediatrics, respectively; p =.01), and they performed more clinical procedures in family medicine (1.9 per student per week versus 0.6 and 1.1 in pediatrics and internal medicine, respectively; p =.001). Students were more likely to encounter specific conditions in internal medicine (35.3 per student per week versus 30.0 and 21.4 in family medicine and pediatrics, respectively; p =.01). Elements of the teaching and learning processes also differed by clerkship. CONCLUSIONS: Very little overlap was found in symptoms, conditions, procedures, and other educational opportunities in the ambulatory pediatrics, internal medicine, and family medicine blocks that constitute the integrated primary care clerkship. The blocks provided different and complementary learning opportunities for students. These findings will assist in clerkship planning and in guiding students to seek opportunities that will ensure educational excellence.