INNOVATIONS IN MEDICAL EDUCATION

A FOURTH YEAR MEDICAL STUDENT ELECTIVE ON THE ADVANCED PHYSICAL EXAMINATION.C.L. Chou¹. ¹University of California, San Francisco, San Francisco, CA. (Tracking ID #117167)

STATEMENT OF PROBLEM OR QUESTION

After their introductory physical examination (PE) course, medical students generally receive little formal guidance and direction to refine their PE skills or to use evidence-based approaches. In addition, there are few examples of learner-centered approaches to the PE in the existing literature.

OBJECTIVES OF PROGRAM/INTERVENTION

1) To review basic PE techniques; 2) to introduce evidence-based approaches to PE techniques; and 3) to solidify students' PE skills by scheduling them to teach in the pre-clerkship PE course.

DESCRIPTION OF PROGRAM/INTERVENTION

A group of ten fourth-year students met for seven three-hour seminars regularly spaced over the course of the two-week elective. Formal seminars for the first week provided time for peer practice, a review of basic epidemiology, a faculty-led seminar on the evidence-based approach to hypovolemia, and a review of useful teaching behaviors and techniques. Students were provided with a list of references from the JAMA Rational Clinical Examination series and were expected to select a question to investigate in depth for eventual presentation to the rest of the elective group. Formal sessions in the second week were then devoted to student-led seminars. In addition, students spent four hours each week teaching and observing pre-clerkship students in the introductory PE course. We provided flexibly scheduled time throughout the two weeks and encouraged students to use this time to practice PE techniques on adult or pediatric outpatients in faculty clinics, inpatients supervised by faculty, or peers.

FINDINGS TO DATE

Students gained confidence in their general PE skills, their teaching skills, and their ability to understand journal articles about evidence-based approaches to physical diagnosis. The aspects of the course that the students found most helpful were preparing and presenting their own seminars, and hearing their colleagues' seminars. The overall rating for the elective was 6.5 (1 = poor, 7 = outstanding).

KEY LESSONS LEARNED

An efficiently-scheduled two-week-long elective, incorporating concurrent patient care duties in which faculty was already engaged, provided a highly rated curricular activity for fourth-year medical students. Students preferred self-directed learning to experiential or didactic approaches. Fourth year electives such as this one may represent a relatively untapped opportunity for students who have completed their core clerkships to consolidate basic skills and to reinforce their clinical experience with an evidence-based approach.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

A GRASS ROOTS ELECTRONIC MEDICAL RECORD (EMR) TO IMPROVE HOUSESTAFF EFFICIENCY, COMPLIANCE WITH DUTY HOURS AND PATIENT CARE.K.B. Armitage¹; R. Rathod². ¹Department of Medicine, Case Medical School/University Hospitals of Cleveland, Cleveland, OH; ²Department of Pediatrics, Case Medical School/Rainbow Babies and Childrens Hospital, Cleveland, OH. (Tracking ID #115795)

STATEMENT OF PROBLEM OR QUESTION

The ACGME duty hour rules implemented in July 2003 requires more efficient approaches to resident education and patient care.

OBJECTIVES OF PROGRAM/INTERVENTION

We identified housestaff progress note writing and the creation of a daily signout to be areas that provided an opportunity for improved housestaff efficiency. Our hopsital is an 850 bed academic medical center without an EMR. We implemented an electronic note writing and signout system for our residents, and then surveyed the residents regarding the time saving of the new system and compliance with ACGME duty hours.

DESCRIPTION OF PROGRAM/INTERVENTION

In October 2003 we instituted a computer based note-writing and signout system that was created by a current PGY2 in Pediatrics at Case. This resident was an IT consultant prior to attending Case Medical School, and prior to his internship created a electronic database system for use by his fellow residents. The system (RECS for Resident Electronic Centralized Signout) works by creating a database for each patient that can then be used to create progress notes and a standardized, formatted signout. Daily progress notes are created by updating patient information from the previous days note and are printed and placed in the patient's chart. Signouts are created using the updated information with little or no additional input. While not strictly an EMR, the data is stored on the hospital's server and is available when patients are readmitted. RECS is an EMR product that may be unique as a system specifically designed to make housestaff more efficient.

FINDINGS TO DATE

We surveyed our interns and residents via email to find out the estimated time savings gained from RECS. Interns on average report time savings of 1.6 hours/day. Residents use the system primarily when interns have the day off and reported time savings of 1.8 hours/day. Based on our informal reporting system, RECS has improved compliance with ACGME duty hours, particularly the “24/6” rule. Nurses and consultants have commented that the notes are legible and clearly identify the patient's service and the houseofficer's pager number. Interns surveyed noted that standardized signouts have improved off-hour coverage.

KEY LESSONS LEARNED

A resident-created EMR system was successfuly adopted by our housestaff. RECS creates efficiencies that improve compliance with duty hours and patient care.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

RECS will be demonstrated at the meeting.

A HANDS ON APPROACH TO TEACHING RESIDENTS AND MEDICAL STUDENTS ABOUT ASTHMA CARE AND GUIDELINES.R.L. Shriver¹; R. Mangold¹; G.A. Salzman¹. ¹University of Missouri-Kansas City, Kansas City, MO. (Tracking ID #115674)

STATEMENT OF PROBLEM OR QUESTION

Asthma is a common chronic disease affecting 14 to 15 million people in the United States. Increasing awareness of the both the disease process and treatment guidelines for asthma among resident physicians and medical students improves delivery of care to patients. Many internal medicine residents and students are unfamiliar with the “Guidelines for the Diagnosis and Management of Asthma” published by the National Institutes of Health (NIH).

OBJECTIVES OF PROGRAM/INTERVENTION

To improve resident physician and medical student knowledge of the NIH “Guidelines for the Diagnosis and Management of Asthma” and thus, improve patient care.

DESCRIPTION OF PROGRAM/INTERVENTION

We have developed a comprehensive asthma care program that includes teaching of residents, medical students and patients, standardized order sets and assistance with developing asthma action plans. Our asthma clinical educator meets with each inpatient service on a bimonthly basis to educate residents and medical students regarding the NIH “Guidelines for the Diagnosis and Management of Asthma.” We have developed an admission and discharge order set that prompts the physician to classify asthma severity and guides them though appropriate treatment, there is a similar set for discharge that requires a completed asthma action plan and prompt follow up in the asthma clinic. During a patient's hospitalization, the clinical educator is available for consult to do patient education and assist the rounding team with choosing appropriate medications and formulating an asthma action plan for the patient to use on an outpatient basis. A staff pulmonologist specializing in asthma care is also available at all times.

FINDINGS TO DATE

This program has improved resident physician and medical student knowledge regarding asthma which has thus translated to improved patient care via shorter and less frequent hospitalizations in our asthmatic population as well as improved compliance with outpatient follow up.

KEY LESSONS LEARNED

Resident physicians and medical students are receptive to using standardized order sets and following treatment guidelines when they are easily available and accompanied by individualized instruction.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Samples of teaching tools, action plan and order sets.

A WEB-BASED SYSTEM TO SUPPLEMENT PRE-CLINIC CONFERENCE.G.H. Tabas¹; R. Granieri¹; J. McGee¹. ¹University of Pittsburgh, Pittsburgh, PA. (Tracking ID #115758)

STATEMENT OF PROBLEM OR QUESTION

Pre-clinic conference at our large institution consists of faculty-led interactive case-based discussions that are repeated on multiple days of the week at three separate sites, accounting for nearly 600 lectures per year. Resident attendance varies because of off-campus rotations and because of ACGME duty hour requirements.

OBJECTIVES OF PROGRAM/INTERVENTION

We sought an alternative way to teach ambulatory medicine to our residents. Studies comparing web-based teaching and written formats have shown that web-based teaching provides greater learner satisfaction and learning efficiency with equal knowledge gained.

DESCRIPTION OF PROGRAM/INTERVENTION

Our system uses Pitt Med Navigator, a web-based program that we customized for our ambulatory teaching modules. Each section of the module begins with a case vignette, followed by a multiple-choice question (MCQ) based on the case. Choosing an answer triggers a brief explanation of why the answer is correct or incorrect. After each MCQ is a brief text page with bulleted points that reinforces the data to be learned and that offers links to supporting literature, practice guidelines, tables, graphs, pictures, and on-line tools. We were careful to limit the length of each text page to maximize the actual amount of text that users would read. A brief user satisfaction survey follows each teaching module. The module ends with a scored post-test consisting of 5 MCQs randomly chosen from a bank of 10 MCQs. Each user has three attempts to score 80% correct and receive credit for the module. The first module, Dyslipidemia, uses guidelines from the National Cholesterol Education Program and has links to an on-line risk calculator, to portions of the guidelines, and to landmark articles.

FINDINGS TO DATE

Of the 56 residents who have completed the module, passing rates on the 1st, 2nd and 3rd attempts were 63%, 23% and 2% respectively. After three attempts 7% did not pass and 5% did not complete the post-test. The average score on the satisfaction survey was 4.14 on a 5-point scale in which 5 was the highest score.

KEY LESSONS LEARNED

Most residents mastered the material in the Dyslipidemia module and were satisfied with the format. We plan to supplement many of our faculty pre-clinic conferences with web-based modules in order to reach a greater proportion of residents and to decrease repetitive faculty lectures. The faculty time required to create each module will be offset by reduced time devoted to repetitive conferences. Faculty-housestaff interaction will be preserved by one-on-one case-based discussions during clinic time.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

We will use a laptop computer with an internet connection to demonstrate the Dyslipidemia module.

A.S.A.P.—TEACHING STUDENTS TO SOLICIT EFFECTIVE FEEDBACK FROM THEIR RESIDENTS.J.M. Riddle¹; S. Frellsen². ¹Rush Universty Medical Center, Chicago, IL; ²John Stoger Hospital? Rush Unversity Medical Center, Chicago, IL. (Tracking ID #117554)

STATEMENT OF PROBLEM OR QUESTION

A number of studies have found that feedback is one of the least frequently observed and most poorly accomplished clinical teaching behaviors. Residents provide a large percentage of the teaching that medical students receive, so are in a position to provide important feedback to students. Although we have conducted yearly retreats to improve internal medicine residents' teaching skills, we had not taught students the principles and skills for soliciting effective feedback

OBJECTIVES OF PROGRAM/INTERVENTION

To develop student skills in soliciting effective feedback from residents and to improve student satisfaction with feedback process.

DESCRIPTION OF PROGRAM/INTERVENTION

We developed a literature-based workshop to teach third year students to solicit feedback. We piloted the workshop with 22 students at the beginning of one of their inpatient medicine rotations. In the workshop we provided an overview about characteristics of effective feedback, followed by a recommended set of skills. The students were taught to Ask for feedback, ask for Specifics, ask for Advice on how to improve and Plan for follow-up on the feedback given. We trained chief medical residents in five scripted scenarios to act as “standardized resident teachers”. In small groups, each of the students practiced soliciting feedback from one of the standardized resident teachers.

FINDINGS TO DATE

Students indicated a high degree of satisfaction with the workshop and an intention to practice the skills during their inpatient rotation. Instruments assessing student's attitudes about feedback and self-efficacy about use of the feedback skills were tested and are being revised. Students showed positive changes in both attitudes and self-efficacy over the four-week rotation.

KEY LESSONS LEARNED

Students enjoy learning through role-play with standardized residents. Our assessment tools appear to measure changes in students' attitudes about feedback. We plan to incorporate the workshop into the internal medicine clerkship orientation.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster showing standardized resident scripts and assessment instruments.

ADVOCACY CURRICULUM PREPARES PRIMARY CARE RESIDENTS FOR ACTIVIST ROLES.M.A. Earnest¹; S.L. Brandenburg¹; L.J. Adams¹. ¹University of Colorado Health Sciences Center, Denver, CO. (Tracking ID #115540)

STATEMENT OF PROBLEM OR QUESTION

Physician advocacy education is particularly important when caring for medically underserved/vulnerable populations as they may not be able to advocate for themselves.

OBJECTIVES OF PROGRAM/INTERVENTION

1. Recognize the vulnerability of patient populations and the unique role of physicians in understanding/identifying their needs. 2. Identify specific approaches for patient advocacy. 3. Provide an opportunity for primary care residents to participate in an advocacy project.

DESCRIPTION OF PROGRAM/INTERVENTION

A longitudinal curriculum ensures that all primary care residents are exposed to physician advocacy. The curriculum includes didactic sessions and the opportunity to participate in a group advocacy project. R1: Introduction to advocacy. Explores how physicians can help address societal problems that contribute to disease and health (case study of a tobacco tax.) R2: Develop specific media advocacy strategies and skills and apply them to the tobacco tax case study; develop specific messages in small groups. R3: Refine and reinforce advocacy skills by critiquing advocacy writing and spoken advocacy messages. Present a panel discussion with leaders in media, government and physician organizations. For residents who demonstrate a higher level of interest, a 1 month advocacy elective is offered, focusing on an advocacy issue of interest to the resident. When possible, they will be paired with a community advocacy group as well as a faculty mentor to help plan and implement an advocacy project focusing on legislation, media, or public education. This was piloted by a future chief resident in 2003.

FINDINGS TO DATE

Pre-curricular attitudinal surveys reflected varying views of physicians' roles in advocacy. Residents will be resurveyed at the end of residency to determine impact of this curriculum. The didactic sessions were rated 4.67 to 5.0 on a scale of 1 to 5, with 5 being most positive. Comments were very enthusiastic and residents felt empowered. The evaluation of the pilot elective was outstanding: “The month spent working on advocacy issues was one of the best learning experiences of my residency. It gave me significant insight into the political and social reasons for the lack of responsible healthcare for the underserved.”

KEY LESSONS LEARNED

Residents are interested in developing advocacy skills. It is important to frame advocacy as an ongoing effort with incremental successes. Having residents work together increases success of the intervention and resident satisfaction.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster.

AN INNOVATIVE APPROACH TO THIRD-YEAR TRAINING.B.R. Ogur¹; D. Hirsh¹; D.H. Bor¹; R. Arky²; M. Cox². ¹Cambridge Health Alliance, Cambridge, MA; ²Harvard Medical School, Boston, MA. (Tracking ID #117499)

STATEMENT OF PROBLEM OR QUESTION

Since medical students' clerkship experiences are mainly inpatient, and they do not develop longitudinal relationships with patients or clinical faculty, they gain an inaccurate view of clinical practice. Decreasing lengths of stay and increasing ambulatory care rarely allow students to see “whole episodes of illness” from initial presentation, through diagnosis, treatment, and outcome. Teaching has become ad hoc, largely relegated to residents, and perpetuating a lack of continuity from pre-clinical education, and diminishing attention to such critical topics as communication skills, professionalism, cultural competence, ethics, physical examination, and epidemiology.

OBJECTIVES OF PROGRAM/INTERVENTION

Our pilot fundamentally restructures clinical education such that all the traditional “core clerkships” are integrated into a single, year-long, clerkship, focused on longitudinal patient care, close mentoring, and group learning.

DESCRIPTION OF PROGRAM/INTERVENTION

1. Central clinical experiences are based on following patients through all venues of care, with the primary sites being ambulatory care centers. 2. Students care for a patient cohort selected to provide a case mix and supervised by a faculty mentor. 3. Didactics are tutorial-based, facilitated by an inter-disciplinary team of faculty. 4. Basic science, clinical medicine, professionalism and key concepts from the social sciences are integrated. 5. Educational portfolios guide learning and provide a vehicle for formative and summative feedback.

FINDINGS TO DATE

Our longitudinal, integrated clerkship is a work in progress with planned implementation in July, 2004. Over 50 faculty, residents, students and educators have participated in planning, with high levels of support for the concept and for the implementation plan.

KEY LESSONS LEARNED

1. Innovative programs based upon adult learning theory must inspire curiosity, self-motivation, and collaborative problem solving, and feel relevant and grounded in prior knowledge. 2. The new program's structure grows directly from understanding the current system's inadequacies and from creating a learning environment which will best prepare students for the world in which they will practice. 3. Curricular change requires building consensus with key collaborators in medical school and hospital leadership and at the sites of patient care delivery.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

We will present diagrams of patient cohort acquisition and of the mechanism for following patients longitudinally, descriptions of the faculty teaching and mentoring roles and demonstration of pilot materials created for the new program.

AN INNOVATIVE COMMUNITY MEDICINE ORIENTATION FOR BRIGHAM & WOMEN's HOSPITAL INTERNS.A.M. Molnar¹; J. Bigby²; J. Katz¹. ¹Brigham and Women's Hospital, Boston, MA; ²Harvard University, Boston, MA. (Tracking ID #117281)

STATEMENT OF PROBLEM OR QUESTION

Entering residents have few opportunities to acquaint themselves with their community, its resources, and the social conditions of their patients during a busy residency.

OBJECTIVES OF PROGRAM/INTERVENTION

—To familiarize entering residents with the neighborhoods surrounding Brigham & Women's Hospital (the neighborhoods where their patients live) and patient's social pressures before beginning patient care activities.—To enhance residents' ability to give patient-centered, culturally competent care.

DESCRIPTION OF PROGRAM/INTERVENTION

All entering interns were given the option to participate in a one day orientation to the community. One-half of the new interns chose to participate (36 interns, 14 leaders). BUILD (Brigham Urban Intern Learning Day) started with breakfast and a slide show describing the demographics of the Boston Healthcare environment. A lively panel discussion followed – Panelists included a state representative for the neighborhood, a community activist for healthcare access, and a community health worker. The participants then divided into three groups to go on walking tours of three of the main neighborhoods from which Brigham & Women's patient population derives—Dorchester/Roxbury, Jamaica Plain, and Mission Hill. In smaller groups of 5–10, the participants worked on a variety of community service projects for the remainder of the afternoon. Projects included: planting trees at a local housing project, sorting free-care applications at a community health center, discussing healthcare professions with teens at a local Latino community center, harvesting at a community garden, cleaning the healthcare van for homeless teens, trail maintenance at Boston Nature Center, etc.

FINDINGS TO DATE

Evaluation of the program is ongoing. Feedback from all participants was extremely positive.

KEY LESSONS LEARNED

A day long orientation to the community is an excellent way to begin residency and is popular among busy entering interns. Community orientation is an enriching experience for entering residents and hopefully allows participants to bring an understanding of their patients' community and social pressures as well as knowledge of available resources to enhance patient care.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster or talk describing the program. Evaluation of the program will be completed by the time of the meeting and will be available for presentation as well.

BALANCING CLINICAL TEACHING WITH CLINICAL PRODUCTIVITY: A TOOL FOR MEASURING TEACHING EFFORT.R.C. Anderson¹; S. Green¹; J. Mitchell¹; M. Almoujahed¹; G. Olds¹. ¹Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #115986)

STATEMENT OF PROBLEM OR QUESTION

Teaching is a core mission of medical schools, but time for teaching may be perceived as under-recognized when faculty teaching efforts are not formally identified. Recruiting faculty for individual teaching programs such as physical diagnosis and ambulatory student rotations may be difficult if faculty view these activities as compromising clinical productivity, and thus, compensation.

OBJECTIVES OF PROGRAM/INTERVENTION

1) To establish a tool in a Department of Medicine that accurately quantifies teaching-related activities; 2) To weight teaching activities based on their impact on faculty clinical productivity, 3) To encourage physical diagnosis and ambulatory student teaching by specifically recognizing the time devoted to these activities.

DESCRIPTION OF PROGRAM/INTERVENTION

The Department's 12-member Education committee developed a comprehensive list of all teaching and teaching administration activities and then assigned a quantity of time to each of these activities. The amount of time assigned was determined following group discussion and consensus of the committee members and then reviewed with the Chairman and Division Chiefs. Decisions about weighting of teaching activities were based on: (1) decreasing (or eliminating) credit for teaching where the learners actually help the faculty look more clinically productive such as inpatient wards, (2) giving partial credit in the ambulatory setting where the learner may slow down clinical productivity (weighted by the experience of the learner) and (3) giving “full credit” for teaching that cannot be done while a faculty member is seeing patients.

FINDINGS TO DATE

This tool has been well received by Division Chiefs and Department faculty. Beginning in July 2003, a percentage of teaching effort was designated for each individual faculty; this is being used in planning for individual overall goals for the year. Expectations for clinical RVUs will be tailored to reflect the amount of teaching time on an individual basis.

KEY LESSONS LEARNED

This tool to quantify teaching clearly defines time for teaching that is not rewarded by publication, title, or salary. It enables modification of appropriate RVU targets for clinical work based on teaching effort. By providing incentive for medical student teaching activities, we expect more willingness for faculty to participate in these activities.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster outlining details of this intervention with display of the instrument utilized for measuring teaching activity.

BEYOND CHART AUDITS IN PRACTICE-BASED LEARNING AND IMPROVEMENT; A CURRICULUM IN QUALITY IMPROVEMENT.A.M. Djuricich¹. ¹Indiana University School of Medicine, Indianapolis, IN. (Tracking ID #115185)

STATEMENT OF PROBLEM OR QUESTION

Practice-based learning and improvement (PBLI), one of the six competencies defined by the ACGME, is particularly challenging for residency educators to implement. Besides performing chart audits, a common way to assess PBLI, residents often have many other innovative ideas to improve processes within the residency program, but previously have not been given a structured tool to organize the implementation of their ideas.

OBJECTIVES OF PROGRAM/INTERVENTION

To create a curriculum in Continuous Quality Improvement (CQI) that teaches internal medicine (IM) residents basic principles of CQI utilizing the Plan-Do-Study-Act (PDSA) cycle, with the following objectives: 1. Demonstrate adequate resident knowledge and skills in CQI processes. 2. Provide residents with the tools to devise their own CQI project ideas on improving systems. 3. Implement residents' projects through hospital, clinic and residency support.

DESCRIPTION OF PROGRAM/INTERVENTION

During their required one-month ambulatory rotation, 3rd year IM residents participated in a CQI curriculum, which included background readings, a brief lecture, and a small group discussion. Residents constructed ideas of their own choosing for CQI projects which had to relate to improving either one aspect of their education or clinical patient care. After receiving feedback by email from a faculty preceptor, each resident presented one CQI project in both oral and written format. Resident skill in understanding CQI methodology was assessed by the written projects. Residents' knowledge and attitudes regarding CQI were assessed with a short answer post-test and self-efficacy reflection. A final grade was determined by the post-test, group discussion participation, and the written project, which was evaluated based on five distinct criteria: adherence to the PDSA cycle, relevance, feasibility, affordability, and ability to measure outcomes.

FINDINGS TO DATE

97% of residents passed the post-test (mean score 88.0%, range 60–100%). All 40 residents to date have designed adequate CQI projects. The mean project score was 38.0 points (maximum: 48; range 16–46). Several projects have been successfully implemented, and others are underway. Global evaluations of the curriculum have been uniformly positive. Residents commented that the timing of the curriculum would be improved if switched into the 2nd year, so projects could be designed with sufficient time for implementation.

KEY LESSONS LEARNED

A structured CQI curriculum can be successfully integrated into an IM residency ambulatory rotation. Residents, eager to make improvements in their residency, clinic and hospital systems, can learn knowledge of CQI principles, as well as the skill of constructing CQI projects within the PDSA cycle framework.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

BRINGING THE CONFERENCE ROOM TO THE BEDSIDE: USE OF A PORTABLE DRY-ERASE BOARD DURING ROUNDS.S. Kripalani¹; D.P. Hunt². ¹Emory University, Atlanta, GA; ²Baylor College of Medicine, Houston, TX. (Tracking ID #117542)

STATEMENT OF PROBLEM OR QUESTION

Bedside teaching rounds promote patient-centered learning, demonstration of clinical skills, and role-modeling of good physician-patient communication. In spite of these benefits, attending physicians and trainees often choose to present patients in a conference room, where the team may use a blackboard or marker board to facilitate discussion. In order to capture the advantages of both settings, we carry a dry-erase board with us during bedside rounds.

OBJECTIVES OF PROGRAM/INTERVENTION

1) To facilitate teaching during bedside rounds. 2) To provide an educational focal point for the ward team.

DESCRIPTION OF PROGRAM/INTERVENTION

We use a flat (i.e., no tray for holding markers), lightweight, plastic-rimmed, dry-erase board, available from any office supply store. While there are many sizes to choose from, either 16 × 20 inches (SK) or 20 × 30 inches (DH) works well, allowing a large writing surface while remaining easy to carry. After hearing the patient presentation, we obtain a focused history from the patient and demonstrate physical examination findings at the bedside. While providing patient education, we sometimes draw simple diagrams on the board to help explain the illness. We then return to the hallway outside the patient's room where immediate teaching points are made. During these discussions, we generally write key points on the board as we help trainees refine the problem list, differential diagnosis, and/or treatment options. The boards are also useful for drawing diagrams of anatomic or physiological relationships, as well as diagnostic or therapeutic algorithms.

FINDINGS TO DATE

The board serves as a focal point for the learning environment on rounds. When the dry erase marker is uncapped, team members always gather around, knowing that the next five to fifteen minutes will be dedicated to teaching. In our experience, students and housestaff pay greater attention and participate more actively when key points are diagrammed or written down. Writing on the board also makes it easier to teach complex relationships, lay out a specific algorithm of medical decision-making, or weigh the advantages and disadvantages of a particular treatment option. Since the main points are written down, the board also benefits students who want to copy information into their own notebooks.

KEY LESSONS LEARNED

Residents and students consistently comment that the simple addition of the dry erase board to bedside rounds has a major visual impact on learning and organization of patient care.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster, demonstration with dry-erase board

CARING FOR THE COMPLEX PATIENT: TEACHING MEDICAL RESIDENTS ABOUT INTERDISCIPLINARY TEAM WORK.M. Schneidermann¹; M. Wheeler¹; E. Tan²; E. Miller³; A. Fernandez¹. ¹University of California, San Francisco, San Francisco, CA; ²Department of Veteran's Affairs, Washington, DC; ³San Francisco General Hospital, SF, CA. (Tracking ID #117096)

STATEMENT OF PROBLEM OR QUESTION

Residents often feel incapable of effectively caring for the complex patients encountered in urban public hospitals, and despite the increased use of interdisciplinary models in clinical practice, resident education remains focused on individual physician-patient interactions.

OBJECTIVES OF PROGRAM/INTERVENTION

The goal of our educational program is to use an existing multidisciplinary clinical project to teach primary care medicine residents how to create and work within interdisciplinary teams to improve their care of complex patients.

DESCRIPTION OF PROGRAM/INTERVENTION

Second and third year primary care medicine residents participate in an educational seminar concentrating on the interdisciplinary management of complex patients. Every two months, a resident presents a challenging clinic patient to members of the High User Case Management (HUCM) team, comprised of social workers, a public health nurse, a psychiatrist, and an internist. The resident prepares a medical and psychosocial assessment of the patient using a format that defines the patient's barriers to care and the goals of treatment. Contributions of each team member are delineated, and clinic and community based resources are described. The resident develops an action plan for a particular clinical issue that engages hospital and community resources, including non-medical staff. Evaluation of the seminar occurs in two ways. Residents survey the sessions rating them on a five point Likert scale (1 poor to 5 excellent) for relevance, contribution to knowledge, and overall effectiveness. Feedback is also elicited through small group discussions.

FINDINGS TO DATE

Eighteen residents participated in seminar and 12 in evaluations. Residents ranked the seminars as highly relevant (mean = 4.5), as contributing to their knowledge (mean=4), and as overall effective (mean = 4.24). Residents also reported that the sessions allowed them to “reframe” their patients' issues, separate out contributing factors, diminish personal frustration with complex patients, and increase their leadership skills with non-physician teams. Residents found the sessions very helpful to their management of individual patients, but were unsure how generalizable this knowledge would be in other healthcare systems.

KEY LESSONS LEARNED

Multidisciplinary clinical programs generate opportunities for resident education. Our case management program for complex patients effectively uses case-based seminars to train residents to use an interdisciplinary approach to care. To improve our curriculum, we will clarify how the seminar's teaching objectives can be applied to other healthcare systems.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

COMPLEMENTARY AND ALTERNATIVE MEDICINE ELECTIVE: AN INTEGRATIVE MODEL.N.L. Nisly¹; M.E. Rosenbaum¹. ¹University of Iowa, Iowa City, IA. (Tracking ID #117172)

STATEMENT OF PROBLEM OR QUESTION

Medical and other health care students are faced with a growing use of Complementary and Alternative Medicine (CAM) practices by their patients, however the traditional medical curriculum does not prepare them to address their patient's use of CAM. Even when knowledgeable of the scientific information on CAM, students are often unfamiliar with the vast number of CAM modalities, which creates a barrier to successfully integrating that knowledge into patient care. We propose that a curriculum which provides evidence-based CAM education coupled with experiential sessions and exposure to CAM providers, enhances the educational experience and better prepares students to address CAM use .

OBJECTIVES OF PROGRAM/INTERVENTION

1. Familiarize health care students with the evidence-based information on CAM, with emphasis on safety and efficacy. 2. Teach effective search strategies for reliable CAM information. 3. Introduce students to philosophical, practical, experiential and scientific information on key CAM modalities, through CAM providers and academic faculty.

DESCRIPTION OF PROGRAM/INTERVENTION

This interdisciplinary elective for medical and other health care students offers multiple learning formats, which are provided by both the medical school faculty and by licensed community CAM practitioners. It includes reviews of the relevant scientific literature, case-based learning and training on effective search strategies for reliable CAM information. Students also meet CAM practitioners, who offer them an unique opportunity to experience various CAM therapies through experiential and shadowing sessions.

FINDINGS TO DATE

The overall elective evaluation including 23 students FY 2001–03 show that 23/23 (100%) students met their expectations, with a mean overall evaluation score of 4.8, in a Likert 1-5 scale. Example of comments: “Prior to this course I had little to no knowledge base of alt meds. I learned things that I had never heard of before. This will help me in my career when working with pts. who use these alt meds”.

KEY LESSONS LEARNED

Our surveys demonstrate the importance of a CAM curriculum in the medical and other health care student education. It also emphasizes the value of incorporating CAM providers in conjunction with the medical school faculty, in providing evidence-based education as well as relevant practical information and experience on CAM. This integrated effort provides an unique opportunity for students to benefit from the strengths of both cultures, improving CAM education.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster and power point presentations, pictures and short video of class activities.

DEVELOPING A COMMUNITY HEALTH FAIR TO PROMOTE COMMUNITY SERVICE BY RESIDENTS.K. DeLisma¹; C. Wiley¹; K. Carr¹; A. Sofair¹; T. Clarke¹; S.J. Huot¹. ¹Yale University, New Haven, CT. (Tracking ID #117139)

STATEMENT OF PROBLEM OR QUESTION

Many students participate in community service activities during medical school, but not residency. We propose that integrating community services activities into residency curricula can promote community involvement, public health education and resident scholarship.

OBJECTIVES OF PROGRAM/INTERVENTION

1. Stimulate and cultivate housestaff and faculty's community services involvement 2. Promote community education and increase health resources awareness 3. Provide opportunities for resident scholarship in areas of community health.

DESCRIPTION OF PROGRAM/INTERVENTION

One resident (KD) developed the health fair as his scholarly project. He recruited faculty mentors (AS, KC, TC, SH) and a colleague (CW) as collaborators. After performing a literature review, goals, objectives, an operating budget and a timeline were developed. Residents, faculty and staff were recruited and contacts with community agencies established. Faculty-resident teams were appointed leaders for each station, fund raising, health fair design and advertising. The fair was held in conjunction with a city-sponsored festival. Stations included: Behavioral Health, Cardiovascular Health, Colon Cancer Screening, Community Health Resources, Low Vision Screening, Immunizations, Nutrition/Obesity/Fitness, Pediatrics, Respiratory Disease, Senior Citizen Resources, Public Health Department, Substance Abuse, Women's Health, and a Blood Drive.

FINDINGS TO DATE

70 residents, faculty, nurses and staff participated in the Health Fair. There were 900 visitors. The first 500 completed a survey and rated their satisfaction with the health fair at 8.7 on a 10-point scale. Of 69 individuals without a diagnosis of diabetes who were screened, 9 were found to be low risk, 31 moderate risk and 29 high risk. All were offered referral. 221 individuals were screened for hypertension and/or hypercholesterolemia. 2 residents are using data from the health fair to develop scholarly projects.

KEY LESSONS LEARNED

A resident champion leader and resident involvement in all aspects of the project were critical as was holding the health fair in conjunction with an existing community activity. Garnering the support of community leaders and educating them about health fair goals was critical for obtaining space and resources from the city. Over 50% of the residents in the training program participated indicating that residents do have a strong interest in community health initiatives. Community service activities provide a rich opportunity for resident scholarship.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster with text, tables and pictures. Laptop computer with rolling PowerPoint.

DEVELOPMENT AND EVALUATION OF A MENTORING PROGRAM FOR INTERNAL MEDICINE RESIDENTS.M.S. Cunnane¹; B. Hanusa¹; R.A. Buranosky¹. ¹University of Pittsburgh, Pittsburgh, PA. (Tracking ID #116612)

STATEMENT OF PROBLEM OR QUESTION

Mentorship is an essential component of successful professional development, but little is known about the effective mentorship of physicians in training.

OBJECTIVES OF PROGRAM/INTERVENTION

Our objectives were to develop and assess a program designed to meet the mentoring needs of Internal Medicine residents at the University of Pittsburgh.

DESCRIPTION OF PROGRAM/INTERVENTION

The Mentorship Program, which assigned a General Medicine faculty mentor to each intern, was implemented in June 2002 to improve residents' personal and professional development. Faculty mentors and interns met at least quarterly to discuss career plans, research opportunities, and time managment. Rotation evaluations and conference attendance reports allowed the mentor to provide feedback about clinical performance; a list of residency requirements enabled mentors to review program expectations. Faculty participated in workshops during the year to enhance their mentoring skills.

FINDINGS TO DATE

To assess the program, a 21-item questionnaire was administered to 68 PGY-2 and PGY-3 Internal Medicine residents, 30 of whom had participated in the assigned mentoring program. Among the 55 residents who completed the survey (81%), 67% identified at least one mentoring relationship: 40% of these were established through the mentoring program (assigned), and 60% were established through free choice (non-assigned). Career guidance and research guidance were noted as areas in which mentoring was desired (86% and 51% respectively), and were subsequently found to be areas in which mentoring occurred for most residents (75% and 47% respectively).There was no significant difference in meeting frequency (p = 0.49), receipt of career guidance (p = 0.88) or receipt of research guidance (p = 0.91) between residents with assigned and non-assigned mentors. Overall, 88% of residents reported benefit; perceived benefit differed significantly between assigned and non-assigned groups (75% vs. 97%, p = 0.04). Among the 1/3 of residents who did not identify a mentor (n = 17), 89% stated that they would have benefited from mentoring, and 58% would have preferred an assigned mentor.

KEY LESSONS LEARNED

Internal Medicine residents have specific needs for mentoring and benefit from mentoring relationships. Assigned mentoring augments existing relationships and provides an opportunity for mentoring to residents who otherwise might not receive it.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

DEVELOPMENT OF A LOW-COST MULTIMEDIA CD FOR CARDIAC AUSCULTATION INSTRUCTION.K. Poindexter¹; D. Torre¹; D.E. Simpson². ¹Medical College of Wisconsin, Milwaukee, WI; ²Society of Directors of Research in Medical Education, Milwaukee, WI. (Tracking ID #116845)

STATEMENT OF PROBLEM OR QUESTION

Previous research has documented gaps in cardiac auscultation skills among medical students. As faculty time to teach becomes increasingly precious the impact of low faculty cost approaches to teaching skills that require practice and repetition must be explored.

OBJECTIVES OF PROGRAM/INTERVENTION

To increase students cardiac auscultation knowledge and skills. To provide a multi-media, self directed learning application for students.

DESCRIPTION OF PROGRAM/INTERVENTION

During the period November to December 2003, thirty-four M3 students who were rotating on their required internal medicine clerkship were given a cardiac auscultation CDROM. The CDROM was developed using Microsoft Producer authoring soft ware; simulated murmurs and heart sounds were provided by Cardionics. The content of the CDROM included seven systolic murmurs, two diastolic murmurs, four heart sounds (S3, S4, and physiologic splitting of S2, fixed splitting of S2) and a pericardial rub. For each murmur/heart sound we developed and synchronize Power Point slides with instructor “voice over”, sound files, and images of the main clinical and auscultatory characteristics of heart sounds/murmurs. At the end of the presentation 8 interactive MCQs with embedded heart sounds were included to test the acquisition of the material. The whole program took 16 minutes to review.

FINDINGS TO DATE

Preliminary results from students' evaluations reveal that >90% of students reported that the CD ROM was easy to use, increased their knowledge and skills of cardiac auscultation, and provided repeated opportunities for practice. Ninety-five percent of students rated the overall educational value of the CDROM very highly and indicated that the CDROM promoted self-directed learning. Student performance on a cardiac simulation test at the end of the clerkship revealed high level of skill acquisition (mean score 11; range 0–12).

KEY LESSONS LEARNED

Students are highly responsive to well structured, CD ROM based learning activities. Because cardiac auscultation skills are learned by practice and repetition this program's multi-media capabilities appears to be an effective and efficient strategy for teaching and reinforcing cardiac physical examination skills to third year medical students. Educators should consider the low cost and high yield of this tool to create and deliver curricular content to medical students.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

CDROM via laptop.

DOES VIRTUAL REALITY SIMULATION TRAINING IMPROVE RESIDENT LEARNING CURVES IN PERFORMING FLEXIBLE SIGMOIDOSCOPIES?J.S. Kunz¹; J. Jorgensen¹. ¹Madigan Army Medical Center, Tacoma, WA. (Tracking ID #117511)

STATEMENT OF PROBLEM OR QUESTION

Does training with virtual reality flexible sigmoidoscopy simulation decrease the number of practice attempts needed on live patients to effectively learn flexible sigmoidoscopy?

OBJECTIVES OF PROGRAM/INTERVENTION

To determine whether practice on a flexible sigmoidoscopy simulator improves the learning curves of internal medicine residents.

DESCRIPTION OF PROGRAM/ INTERVENTION

Eight internal medicine residents at the PGY-1 level were divided into groups of four. The study group received six hours of instruction on the flexible sigmoidscopy virtual reality simulator; the control group did not receive the simulator training. The two groups then performed sigmoidoscopies on live patients under staff supervision and were asked to fill out a follow up questionnaire after each procedure that determined whether the procedure was successful (criteria for success based on whether the resident achieved at least 35cm of insertion, conducted the procedure in less than 20 minutes, performed an adequate retroflexion, and performed the procedure independently). Failing any of the preceding categories was considered a procedural failure. Cumulative sum analysis was then used to construct learning curves for each of the eight residents. The Mann-Whitney U test was utilized to describe the statistical significance among these non-parametric results.

FINDINGS TO DATE

The number of attempts needed to learn flexible sigmoidoscopy in the control group was 19+/−5, whereas the number of attempts needed to learn flexible sigmoidoscopy in the experimental group was 10+/−4 (P < .04).

KEY LESSONS LEARNED

The use of virtual reality flexible sigmoidoscopy simulation is an effective training tool and appears to decrease the number of attempts it takes to successfully learn how to do a flexible sigmoidoscopy on a real patient.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

EFFECTIVENESS OF A HIP FRACTURE SERVICE AS A GERIATRIC TEACHING INTERVENTION IN AN INTERNAL MEDICINE RESIDENCY PROGRAM.L.N. Miura¹; E. Eckstrom¹; E. Meihoff¹; L. Homer¹; S. Jones¹. ¹Legacy Portland Hospitals, Portland, OR. (Tracking ID #116439)

STATEMENT OF PROBLEM OR QUESTION

As the population ages, preparing future physicians to practice medicine with a focus on geriatrics becomes paramount. Various educational strategies for training housestaff, specifically those in internal and family medicine, have been proposed. We developed a geriatrician-led hip fracture service in 2001 to improve care to this elderly population during a high-risk procedure. We realized this new program was an ideal opportunity to teach internal medicine residents how to manage complex geriatric inpatients.

OBJECTIVES OF PROGRAM/INTERVENTION

To determine if a one month rotation on the hip fracture service could 1) increase resident knowledge of perioperative and geriatric medicine, 2) improve comfort level in caring for the acutely ill geriatric patient, and 3) demonstrate satisfaction with participation in such a rotation.

DESCRIPTION OF PROGRAM/INTERVENTION

Thirty-eight second-year internal medicine residents based at an academic-affiliated community hospital rotated for one month on the hip fracture service from 2001–2003. The residents rounded daily with the geriatrician and participated in the work-up and management of patients admitted to the service. Twice weekly didactics on perioperative medicine and topics such as delirium, pressure ulcers, and constipation were taught by the geriatrician. Residents completed a 7-item survey following this experience. Knowledge and comfort level in managing these patients was evaluated with a five-point Likert scale (1 = least, 5 = most). Responses were analyzed using a sign test.

FINDINGS TO DATE

Thirty-six of 38 residents (94.7%) responded. Resident satisfaction with the service was high, with a score of 4.1 (range 2.0–5.0). All 36 residents felt better able to handle acute hip fracture patients (P < .001), and 31 of 36 felt more comfortable with perioperative management (P < .001). Residents reported increased knowledge in pain management (80.6%), delirium (50.0%), and bowel regimens (36.1%) as other valuable lessons learned on the service.

KEY LESSONS LEARNED

Resident self-reported proficiency in the perioperative management of the elderly patient with acute hip fracture, as well as knowledge in several basic geriatric medicine topics, improved after rotating on a geriatric hip fracture service. Although we had no control group for comparison, this program appears to be an effective model for teaching geriatrics to housestaff in internal medicine. Furthermore, residents were very satisfied with this experience, suggesting we have found one way to enhance resident interest in caring for geriatric patients.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

ENHANCING M4 STUDENT EBM SKILLS USING PBL AND PEER TEACHING.R.C. Anderson¹; J. Zebrack¹; D. Torre¹; D.E. Simpson¹. ¹Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #117311)

STATEMENT OF PROBLEM OR QUESTION

M4 students must prepare to be lifelong learners per the AAMC outcome objectives report. Evidence-based medicine skills are a core component of self-directed learning.

OBJECTIVES OF PROGRAM/INTERVENTION

(1) To generate EBM clinical questions utilizing a problem-based learning (PBL) case-based session; (2) To increase efficiency in asking, acquiring, appraising, applying and assessing best evidence; (3) To solidify EBM knowledge and skills through teaching of EBM to peer students; (4) to enhance self confidence of EBM skills.

DESCRIPTION OF PROGRAM/INTERVENTION

M4 students (5–8 students) during a required month of Ambulatory Medicine participate in a PBL session using a patient case to generate relevant clinical questions. Students then identify EBM resources and use a self-accountability process to frame goals, methods and outcomes for filling EBM knowledge and skill gaps specific to each student. Findings are presented in a conference to their fellow M4 students and a group of approximately 10 M3 students who also are on Ambulatory Medicine. At the conclusion of this intervention, students rate their confidence in EBM skill areas (ask, acquire, appraise, apply, assess) and then retrospectively rate their confidence in these same areas at the beginning of the month. A T-test was utilized to compare mean ratings of self-confidence before and after the intervention (Likert scale 1–5).

FINDINGS TO DATE

13 M4 students have completed this intervention to date. Each EBM skill area (ask, acquire, appraise, apply, assess) as well as teaching skill shows significant improvement in self-confidence (P < .05). The students rated the overall intervention as very beneficial and highly valued the opportunity to learn from and teach student peers.

KEY LESSONS LEARNED

This intervention is effective in increasing the confidence of M4 students in their EBM skills. A problem-based learning approach helped to identify pertinent clinical questions and a self-accountability process framed specific outcomes for each student. Finally, teaching to student peers solidified EBM skills.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster outlining details of the educational intervention. Copies of actual instruments used for assessment and examples of M4 products will be available.

EVIDENCE-BASED MEDICINE IN 7 HOURS: AN AMBULATORY CURRICULUM.D. Zipkin¹; G. Khanna¹. ¹California Pacific Medical Center, San Francisco, CA. (Tracking ID #102296)

STATEMENT OF PROBLEM OR QUESTION

Teaching residents to practice Evidence-Based Medicine (EBM) is imperative in order for them to provide up-to-date, cost-effective primary care. Time constraints make effective EBM teaching a challenge.

OBJECTIVES OF PROGRAM/INTERVENTION

To incorporate EBM into ambulatory teaching in a community-based categorical internal medicine residency program, emphasizing critical review of published studies in answering clinical questions.

DESCRIPTION OF PROGRAM/INTERVENTION

Categorical residents at California Pacific Medical Center in San Francisco spend one month per year in the primary care clinic. During a four week block, the curriculum is presented to 2–3 residents over seven hours. The components are: 1. Asking a clinical question, focused on the framing of a well-conceived question (1 hour) 2. Understanding study design— a review of the uses for cohort studies, case-control studies, clinical trials and systematic reviews (45 min) 3. Sample journal club—a presentation by faculty of a major current article (30 min) 4. Literature search skills—a computer session reviewing PubMed and Ovid search techniques (45 min) 5. Diagnosis—a review of sensitivity, specificity, likelihood ratios, pre- and post-test probabilities, and clinical application using a sample article and worksheet (1 hour) 6. Screening—a review of the concepts of lead time bias, length time bias and study design, using a sample abstract (30 min) 7. Treatment and Harm—a review of relative risk reduction, absolute risk reduction, number needed to treat/harm, using a sample article and worksheet (1 hour) 8. Prognosis—a review of the concepts of inception cohort and bias, using a sample abstract (30 min) 9. Journal club—presentation of articles by the residents, based on their clinical question (1 hour).

FINDINGS TO DATE

Seven residents have completed the program to date. Evaluations include pre- and post-tests of residents' self-reported knowledge and attitudes as well as course feedback forms. Overall feedback from residents has been uniformly positive. After completing the curriculum, residents are more likely to agree that they can find the best evidence to answer their questions and apply it to clinical practice. They are more confident in defining terms such as relative risk, likelihood ratio, and number needed to treat. Skills are assessed through participation in applying concepts as well as the journal club presentation. Evaluation of residents' performance is incorporated into the rotation evaluation.

KEY LESSONS LEARNED

EBM can be taught effectively in the ambulatory setting within a limited time frame.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

FACULTY DEVELOPMENT IN GERIATRICS TEACHING FOR SURGEONS AND SUBSPECIALISTSB.C. Williams¹; J.T. Fitzgerald¹; J.B. Halter¹. ¹University of Michigan, Ann Arbor, MI. (Tracking ID #116459)

STATEMENT OF PROBLEM OR QUESTION

The large and growing number of older patients requires that non-primary care physicians possess basic skills in geriatrics.

OBJECTIVES OF PROGRAM/INTERVENTION

To develop geriatrics clinical and teaching “champions” among surgical and medical subspecialty faculty by, a) teaching faculty a comprehensive framework, clinical knowledge, and assessment skills in geriatrics relevant to their discipline, b) supporting faculty in developing and implementing a geriatrics curriculum for house officers in his/her discipline, and c) disseminating results within each specialty and subspecialty, and to medical educators.

DESCRIPTION OF PROGRAM/INTERVENTION

One faculty member from each of 6 medical subspecialties, 6 surgical specialties, Anesthesiology, Emergency Medicine, and Physical Medicine was recruited for participation (n = 15). Faculty were enrolled in 4 separate cohorts 6–12 months apart, and participated in 9–12 months of weekly 2-hour small group seminars. Seminars were highly interactive and included frequent presentations by participants. Resources to assist lead faculty include: a) a web-based teaching resources warehouse, b) an internal clinical website containing resource and referral information in geriatrics, and c) a Standardized Patient Instructor program for developing assessment and communication skills among house officers.

FINDINGS TO DATE

Of the 15 participating faculty, 11 have completed most or all the faculty development seminars, one has dropped out, and 3 begin January, 2004. Positive outcomes include: a) faculty report that the seminars were helpful and relevant, and increased their confidence in teaching and doing geriatrics, b) increased faculty knowledge in geriatrics, c) numerous new lectures and clinical rotations in geriatrics, and d) faculty are recognized as geriatrics “champions” in their home departments or divisions. Difficulties include: a) two faculty left the institution to enter clinical practice, b) time was not always protected, especially among surgical faculty, and c) implementing clinical teaching programs has been limited in some disciplines.

KEY LESSONS LEARNED

Non-primary care faculty development in geriatrics requires motivated faculty supported by department or division chairs, and substantial protected time. Regular, longitudinal, interactive small group seminars that require faculty to demonstrate skills and report progress are key to successful implementation. Early and ongoing efforts should be made foster support from home departments, and to maintian enthusiasm and ongoing learning and teaching by geriatrics-trained faculty after leaving the formal program.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster, teaching syllabi, static Web displays.

FELLOWS AS CLINICIAN EDUCATORS: TEACHING AND EDUCATION SKILLS DEVELOPMENT FOR FELLOWS.B.E. Johnson¹; M.E. Rosenbaum¹. ¹University of Iowa, Iowa City, IA. (Tracking ID #117012)

STATEMENT OF PROBLEM OR QUESTION

Internal medicine (IM) departments often hire recent IM fellows to function as clinician educators. But IM fellowships are challenged to provide training in teaching and education skills to match training in research. Teaching skills development requires faculty and medical educator expertise, time and expense; often too few fellows are in any one division to sustain a teaching program.

OBJECTIVES OF PROGRAM/INTERVENTION

We started the Fellows as Clinician Educators (FACE) program to fill this void. The objectives of the FACE program are: 1) to enhance skills in teaching, curriculum development and career planning for a cross-disciplinary group of IM fellows and, 2) to provide this training in a time- and cost-saving setting for the department of internal medicine and IM specialty divisions.

DESCRIPTION OF PROGRAM/INTERVENTION

The FACE program accepts interested fellows in any specialty division. The first year focuses on presentation and teaching skills enhancement. The second year consists of curriculum development and career planning. By the end of their second year, the participant should have a completed curricular element and a nascent teaching portfolio. Seminar-type sessions consist of didactics, self-assessment exercises, skill-practice activities, and discussion. Little “homework” is assigned beyond writing of a curriculum and compiling ones teaching portfolio. To enhance teaching skills outside the clinical setting, participants lead small groups of pre-clinical medical students. Fellows are observed while teaching and given formal feedback

FINDINGS TO DATE

23 fellows, from 7 specialty divisions, have participated in the FACE program. Pre-program self-assessments show a desire to improve skills in lecturing, small group facilitation, and inpatient and outpatient teaching. Participants are involved in varying levels of teaching. Fellows who have completed the two-year FACE program have successfully written curriculum and begun a teaching portfolio. There are not enough data for pre/post-program comparison or to assess effect on career paths.

KEY LESSONS LEARNED

The FACE program provides future clinician educators teaching and educational skills development in a cross-disciplinary setting that may be missing in specialty fellowships. Strong financial and administrative support from department leaders confirms the consolidation of effort and manpower represented by this program.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

FOCUSING ON THE DOCTOR's CULTURE: A FRAMEWORK FOR TEACHING CULTURAL COMPETENCE TO FIRST YEAR MEDICAL STUDENTS.C. Boutin-Foster¹; L. Konopasek¹; S. Morales¹; P. Marzuk¹; C.L. Storey-Johnson¹. ¹Cornell University Medical College, New York, NY. (Tracking ID #116462)

STATEMENT OF PROBLEM OR QUESTION

Traditionally, cross-cultural curricula have focused on the patient's culture as being different. This approach may inadvertently suggest that the physician's culture is the norm or may reinforce stereotypes about specific cultural groups. A critical, yet often neglected aspect of cross-cultural curricula is that physicians, as a professional group, also have a unique set of values, beliefs, and behaviors that may influence their interactions with patients.

OBJECTIVES OF PROGRAM/INTERVENTION

The goal of the program is to enable students to: 1) understand the principles of cultural competence and 2) appreciate that the physician's culture can influence the doctor-patient interaction.

DESCRIPTION OF PROGRAM/INTERVENTION

This program is taught as part of the cultural competence curriculum of the first year doctoring course. The format is a 1.5-hour lecture consisting of a didactic session, self-reflection exercises, and clinical vignettes. Students participate in a series of exercises that illustrate the influence of the medical profession on their values and the influence of medical education on their views on health and illness. These exercises also illustrate the shared patterns of behaviors of physicians for example, their use of medical jargon. Clinical vignettes are used to illustrate how physician's culture can contribute to health disparities. Students evaluate the program by rating the extent to which it has aided their learning. Their knowledge and attitudes are assessed through a written exam. As part of the exam, they are shown a videotaped doctor-patient encounter in which the doctor and patient have concordant ethnicity and gender and are asked to describe the role of cultural competence in the encounter.

FINDINGS TO DATE

A total of 102 first year medical students participated in this course. Of these, 82% rated it as a helpful learning experience. On the written exam, most students demonstrated knowledge of the principles of cultural competence and demonstrated an awareness that the physician's culture can also influence the doctor-patient interaction.

KEY LESSONS LEARNED

Our findings suggest that discussing the physician's culture is an essential component of teaching cultural competence to first year medical students. Future work will focus on evaluating the impact of this course on clinical skills through OSCEs and determining whether the principles learned are sustained beyond the first year of medical school.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Clinical vignettes and videotapes used in the course will be available.

FROM CLASSROOM TO CLERKSHIP: A CURRICULUM FOR FIRST YEAR MEDICAL STUDENTS.P. Basaviah¹; J.H. Muller¹; L. French¹; C.L. Chou¹; W.B. Shore¹; C. Chen¹; L. Tong¹. ¹University of California, San Francisco, San Francisco, CA. (Tracking ID #117492)

STATEMENT OF PROBLEM OR QUESTION

Students can have significant difficulty adapting to the “ward culture.” Further, medical students often complain that they do not see the clinical relevance of basic science instruction.

OBJECTIVES OF PROGRAM/INTERVENTION

A four-day curriculum occurring three months into medical school, “Clinical Interlude (CI),” was designed to introduce first-year medical students to the culture of the inpatient setting and to provide them with a context for the classroom material they are learning. Specific goals included: (1) observing patient-clinician relationships; (2) understanding dynamics of health care teams; (3) learning about the hospital experience from a patient's perspective; and, (4) delineating roles of non-physician health care providers.

DESCRIPTION OF PROGRAM/INTERVENTION

CI has been implemented in December 2001–2003 at UCSF for all first-year medical students (~140). Each student was assigned to an inpatient setting in one of 6 hospitals, to one of 11 clinical areas, and to one of 10 health care professional categories. The curriculum consisted of five key components: (1) a keynote speaker who was a clinician with a chronic illness herself; (2) a day of observation and interaction with inpatient teams during work rounds, bedside rounds, and didactic sessions; (3) an interview and exam of a hospitalized patient; (4) a session with a non-physician health care provider; and, (5) a small group to discuss reflections, facilitated by a faculty facilitator.

FINDINGS TO DATE

CI was highly rated in 2001 and received even higher ratings in 2002. On a rating scale of 1 = poor to 5 = excellent, overally quality scores improved from 3.8 in 2001 to 4.37 in 2002. Overall, ratings improved in 2002, with 66% rating the overall quality as very good or excellent in 2001 and 87% in 2002. Subjective assessments included students' answers to questions about the inpatient setting. Topics were based on their observations and included: discoveries about inpatient settings and teams, predictors of successful inpatient teams, and predictors of patient satisfaction.

KEY LESSONS LEARNED

The majority of students reported that the curriculum helped them recognize the importance of communication within teams, with non-physician health care providers and with patients. Students also recognized they can have control in defining the kind of physicians they will become. In conclusion, early clinical experiences provided first-year medical students with new insights and motivation for learning.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster, brochures, powerpoint/lcd (latter optional).

HARNESSING RESIDENT INTEREST AND INITIATIVE FOR EXCEPTIONAL LEARNING: THE CREATION OF A WEIGHT MANAGEMENT CLINIC.M. Jay¹; D. Mann¹; S. Zabar¹. ¹New York University, New York, NY. (Tracking ID #116578)

STATEMENT OF PROBLEM OR QUESTION

How can residents translate their interest in a global health epidemic into a sustainable project that advances health care delivery?

OBJECTIVES OF PROGRAM/INTERVENTION

The objective of the program is for residents to learn how to generate new systems of patient care through the creation of a weight management clinic.

DESCRIPTION OF PROGRAM/INTERVENTION

After completing an advocacy project on obesity prevention and treatment for their health policy course, three NYU Primary Care third year residents identified a need to establish a clinic to address weight management. They discussed their ideas with the medical director and initiated meetings with a behavioral therapist, a nutritionist, and interested attendings. Through these meetings, an 18-week program was developed that focused on lifestyle change using standard cognitive behavioral techniques, nutrition, exercise demonstrations, and problem solving sessions. Residents screened all patients for eligibility and collected baseline information. Enrolled patients met for weekly group sessions run by residents and a multidisciplinary volunteer staff.

FINDINGS TO DATE

Three senior residents spent an average of 4–8 hours per week over a 10-month period on planning and implementation. Four junior residents spent 3–4 hours per week during their ambulatory blocks. They managed 3 groups of patients through completion. The residents developed expertise in the multidisciplinary management of obesity; acquiring skills in patient recruitment, group session management, and clinic administration. The residents also experienced collaborative relationships with specialties including bariatric surgery, endocrinology, and gastroenterology for joint clinical and research projects. The challenges of implementation included finding appropriate clinical and administrative mentorship, funding, and sustainability.

KEY LESSONS LEARNED

Residents achieve excitement, energy, and scholarship by learning about healthcare organization and management through researching an important community health need, seeking mentorship from diverse disciplines, and designing and implementing a new clinical service.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

A poster and other materials.

HOW TO IMPLEMENT A PROFESSIONALISM CURRICULUM ACROSS THE ENTIRE DEPARTMENT OF MEDICINE.R.C. Anderson¹; M. Lodes¹; J. Franco¹; D. Torre¹; J. Sebastian¹. ¹Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #117321)

STATEMENT OF PROBLEM OR QUESTION

Professionalism is a cornerstone of physician practice and medical education. The ACGME and LCME require a consistent approach to teach and evaluate professionalism in a Department of Medicine.

OBJECTIVES OF PROGRAM/INTERVENTION

(1) To develop and implement a comprehensive program to address professionalism in faculty, fellow, resident and student activities; (2) To enhance mechanisms for feedback and follow-up of professionalism issues; (3) To better document and understand perceptions of unprofessional behavior.

DESCRIPTION OF PROGRAM/INTERVENTION

The Department of Medicine Education Committee was tasked by the Department Chairman to develop and implement a comprehensive professionalism curriculum for the Department. A subcommittee of faculty (1 female, 2 male) was identified as the core advisory group for students. Identified medical student leaders communicate to the subcommittee any student-identified issues that arise on Department of Medicine rotations. The Department residency and fellowship programs are being targeted with a series of case-based scenarios at morning report, fellows' conference and resident retreats.

FINDINGS TO DATE

Student liaisons are reporting 1 to 2 situations per 2-month block and anonymous student evaluations are showing 3 to 4 situations. One serious faculty issue was identified. Residents report satisfaction with case-based scenarios as means to frame discussion of unprofessional issues.

KEY LESSONS LEARNED

Student liaisons are not reporting all situations perceived as unprofessional. The reported episodes have led to specific actions including removal of a clinical faculty from teaching responsibilities and development of a case scenario based on an unprofessional resident-student interaction. An anonymous reporting system might be helpful to capture more situations perceived as unprofessional. Case-based scenarios are effective teaching tools for residency education.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster detailing educational strategies for student, resident and fellow education. Examples of case scenarios will be provided as handouts.

IMMERSION EDUCATIONAL EXPERIENCE FOR TEACHING ESSENTIAL CLINICAL SKILLS TO FIRST-YEAR INTERNAL MEDICINE RESIDENTS.K.J. Pfeifer¹; L. Moraski²; S. Bamrah¹; I.A. Gilbert¹; S. Davids¹. ¹Medical College of Wisconsin, Milwaukee, WI; ²Medical College of Wisconsin, Wauwatosa, WI. (Tracking ID #117351)

STATEMENT OF PROBLEM OR QUESTION

Pressures to comply with work hour limitations combined with increasing variability in first-year resident skill sets make traditional educational venues insufficient for optimizing ACGME competency-based graduate medical education.

OBJECTIVES OF PROGRAM/INTERVENTION

Internal Medicine 101 (IM101) is a five-day course for first-year internal medicine residents intended to build a foundation of core skills and lifelong learning. It is designed to strengthen and enhance critical clinical skills, teach the basics of academic and professional development, introduce the concepts and methodology of systems-based practice and foster collegial and mentoring relationships between residents and key teaching faculty.

DESCRIPTION OF PROGRAM/INTERVENTION

Using the ACGME Core Competencies as framework, we created a forty-hour series of small group, interactive educational sessions for all first-year internal medicine residents (categorical and combined programs). Sessions focused on physical diagnosis, clinical test analysis, communication skills, systems-based practice and professional development. The course was limited to ten residents per 5-day session, and residents were relieved of all other duties. Sessions were led by faculty previously recognized for both excellence in teaching and expertise in given topics.

FINDINGS TO DATE

All resident (n = 24) and faculty (n = 13) participants completed post-course surveys using a five-point Likert scale (1= worst and 5 = best). Residents rated the course highly in all areas with mean ratings for overall course effectiveness, preparation for career and strengthening of professional relationships of 4.6, 4.5 and 4.5, respectively. Resident data supports this course as a worthwhile utilization of resident time as compared to other educational programs (mean 4.8) and should be offered again the following year (mean 4.9). Similarly, faculty found the course to be a good opportunity to increase interaction with residents (mean 4.7) and a better use of their teaching time (mean 4.6). They also characterized the residents as more engaged (mean 4.7) and their teaching as more effective (mean 4.5) in the IM101 course. Residents also completed pre- and post-course skills self-assessments and objective skills testing, and analysis of these data is in process.

KEY LESSONS LEARNED

IM101 is an effective means to integrate the ACGME Core Competencies into residency training. Overall, we found that IM101 resulted in high satisfaction and incorporation of a basic skill set across all residents, and anticipate follow-up data that shows sustained change in performance over time.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

INTEGRATING GERIATRICS AND VIRTUAL PATIENTS INTO THE MEDICAL SCHOOL CURRICULUM.K. Denson¹; D. Kerwin¹; D. Simpson¹; E. Duthie¹. ¹Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #115693)

STATEMENT OF PROBLEM OR QUESTION

The aging population and associated demands on the health care system have led to revised accreditation standards requiring that geriatrics be integrated into an already dense medical school curriculum.

OBJECTIVES OF PROGRAM/INTERVENTION

To implement a sustainable approach to increasing geriatrics education that is clinically relevant and permits longitudinal follow-up of geriatric conditions throughout the four years of medical school education. Our goal is to integrate geriatric medicine into the already present curriculum by providing video, still images and other materials in CD-Rom form that could be integrated into existing lectures.

DESCRIPTION OF PROGRAM/INTERVENTION

Five paper cases, each abstracted from an actual patient's chart, were developed to highlight common geriatric conditions and the progression of disease over time as the patients age 15–25 years. The cases were then presented to basic and clinical science faculty who had teaching responsibilities linked to the case topics (e.g. dementia, diabetes, osteoporosis, hypertension) to make modifications in the case and the progression of disease over time which would enhance incorporation of the case into their teaching. Faculty identified additional resources needed (e.g., radiographic images, lab findings) that would enhance case utility. The CD-Rom, in effect, makes the patient “come alive”. CD accessible resources have been assembled for five cases and include 20–30 video vignettes per case using geriatricians and professional actors who “age” and change health status in response to disease progression. Still images, genograms, radiologic images and histology slides are also incorporated into each CD to increase the available teaching resources.

FINDINGS TO DATE

The result is the creation of CD-Rom teaching tools that are used in the medical school curriculum to increase exposure of students to geriatric topics and principles and to supplement lecture content. The CDs have been well received by both the faculty and students over the last two years. In the initial 15 months, across the M1–M3 years 67% of the required courses and clerkships incorporated at least one case into the curriculum. During the M1–2 years over half of the required courses used the first two cases: M1 cases were used 18 times, M2 used 9 times. In comparing the 2001 and 2003 AAMC Senior Graduation Questionnaires the knowledge of healthy adults increased over 10% and adequacy of geriatrics training during clinical clerkships increased over 17%. In addition, students' perception that geriatrics education was part of all four years of their medical education increased from 25% to over 60%.

KEY LESSONS LEARNED

The accessibility of peer-developed, longitudinal geriatric cases, explicitly linked to basic and clinical science topics and associated images, video clips and teaching resources, is an effective and efficient strategy for increasing geriatric content within the medical school curriculum. Steps now involve further measurement of the use of the teaching CDs in the curriculum and the creation of a similar set of CDs that will focus on assessment of the topics presented to correspond with the ACGME Internal Medicine Training Program Requirements.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Demonstration of our teaching CDs will allow participants to individually use the computer to view the cases, video clips, radiographic images and lab findings contained on teaching CDs. In addition, a poster will be presented to highlight the impact of the CDs upon medical student education in the area of geriatrics.

INTEGRATING GERIATRICS INTO AN INTERNAL MEDICINE AMBULATORY CURRICULUM: TIME FOR A SENIOR MOMENT.M.M. Ziebert¹; J.L. Mitchell¹; M. Schapira¹; D.E. Simpson². ¹Medical College of Wisconsin, Milwaukee, WI; ²Society of Directors of Research in Medical Education, Milwaukee, WI. (Tracking ID #115512)

STATEMENT OF PROBLEM OR QUESTION

The aging of our population together with the shortage of physicians trained in geriatrics demands that the care of the elderly become a focus for internal medicine residency training. Currently, barriers to implementing optimal geriatric teaching by academic generalists include insufficient curricular time, motivation, and resources.

OBJECTIVES OF PROGRAM/INTERVENTION

To improve the geriatric knowledge, skills, and attitudes of internal medicine residents and address barriers to teaching geriatrics by embedding geriatrics within existing core curriculum topics.

DESCRIPTION OF PROGRAM/INTERVENTION

Our current internal medicine ambulatory care curriculum includes a weekly conference that takes place before the continuity clinic sessions. At the conclusion of this conference, the residents now pause for a “Senior Moment.” Residents are asked to consider whether the concepts highlighted in the conference can be applied to the care of the elderly. Using an unfolding case format with an emphasis on EBM and a reference article, the residents and faculty preceptor are prepared to discuss the geriatric focus.

FINDINGS TO DATE

In a review of the 46 ambulatory care topics in one academic year, 17 (37%) were appropriate for adaptation to Senior Moments. The following 7 topics were developed and implemented—hypertension, cancer screening, hyperlipidemia, valvular heart disease, osteoarthritis, sinusitis, prostate cancer and hyperlipidemia. An evaluation of the innovation was done from the resident and attending perspective. A sample of residents from one clinic site (n = 67) completed a post-conference questionnaire after each of the seven completed Senior Moments. Ninety-nine percent (99%) agreed that the Senior Moments would help them care for geriatric patients. A structured interview was conducted with a representative group of faculty preceptors who had used the Senior Moments in order to explore factors that influence its use. The faculty valued the Senior Moments' unfolding case format and the EBM emphasis, found the most effective Senior Moments to be those that emphasized functional assessment, and reported that they could incorporate this instructional method with only limited preparation. To strengthen the Senior Moments, faculty recommended highlighting the relevant ACGME competencies within each case and using time management skills to insure that sufficient time is allocated within the conference for the Senior Moment. KEY LESSONS LEARNED: The Senior Moment can enhance common ambulatory care topics by adding a geriatrics perspective to existing conference series discussions rather than initiating a separate curriculum. The Senior Moment's flexibility allows the faculty to emphasize clinical studies that enrolled elderly patients, guidelines for treatment in the elderly and/or geriatric functional assessment to meet the ACGME competencies.

KEY LESSONS LEARNED

Poster with ambulatory care curriculum and examples of prepared Senior Moments.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

INTEGRATING LEARNING MODELS FOR NEW GENERAL COMPETENCIES INTO AN INTERNAL MEDICINE RESIDENCY TRAINING PROGRAM.S. Wali¹; P.P. Balingit¹. ¹UCLA San Fernando Valley Program, Sylmar, CA. (Tracking ID #117552)

STATEMENT OF PROBLEM OR QUESTION

Residency programs must require its residents to obtain outcomes-based general competencies in six areas to the level expected of a new practitioner. Internal medicine residency programs are charged with creating novel strategies to teach and evaluate these new competencies.

OBJECTIVES OF PROGRAM/INTERVENTION

To design, implement, and evaluate experiential learning models in three of the new outcomes-based competencies introduced by the ACGME: practice-based learning and improvement, systems-based practice, and professionalism.

DESCRIPTION OF PROGRAM/INTERVENTION

The learning modules included the following components: 1) As part of their two to three month ambulatory medicine rotation, PGY-2 and PGY-3 residents participate in a 4-week evidence-based medicine curriculum, using a case-based format derived from actual scenarios encountered in clinic. Each resident receives a syllabus and completes a series of readings on general principles and specific methods used in applying the medical literature to the clinical practice of medicine. 2) PGY-2 and PGY-3 residents participate in Collaborative Care Rounds during their ward rotations. Members from the hospital care team, including social work, utilization review, physical therapy, public health, and home health meet biweekly with residents to provide input regarding patient care plans. Residents are evaluated on awareness of and responsiveness to the larger context and system of health care and the ability to effectively utilize resources. 3) Feedback is collected and reviewed quarterly from satisfaction surveys distributed to patients under the care of PGY-1, PGY-2, and PGY-3 residents in the continuity clinic and on inpatient ward services. Additionally, nursing and clerical staff are asked to evaluate housestaff on their commitment to carrying out professional responsibilities and sensitivity to a diverse patient population.

FINDINGS TO DATE

The newly-developed learning modules have been well-received. Preliminary data indicate a greater understanding of the knowledge, skills, and attitudes required in obtaining the three general competencies studied, as evidenced by resident responses on self-evaluation questionnaires administered prior and after participation in each module.

KEY LESSONS LEARNED

A curriculum which includes experiential learning modules to teach and evaluate the core competencies introduced by the ACGME is essential and feasible. Residents appreciate that attainment of these general competencies is necessary to become successful practitioners.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Oral or poster presentation, with samples of curricular materials.

INTERACTIVE, CASE-BASED WORKSHOPS: A NOVEL APPROACH TO TEACH CLINICIANS GERIATRICS AND GERIATRICIANS INTERACTIVE TEACHING. J. Brand¹; H. Fernandez¹; R.M. Leipzig¹. ¹Mount Sinai School of Medicine, New York, NY. (Tracking ID #116357)

STATEMENT OF PROBLEM OR QUESTION

As the population ages, improving practicing physicians' ability to care for older adults is increasingly critical. Continuing medical education (CME) is the traditional approach to increasing knowledge and improving practice. Historically didactic, previous physician surveys on CME delivery format have demonstrated the desire for increased personal interaction. Under the John A. Hartford Foundation and American Geriatrics Society sponsored Practicing Physician Education (PPE) project, two hour teaching sessions and toolkits were developed based on a physician survey which identified key geriatric topics to assist practitioners in evaluating and treating the most common Geriatric Syndromes.

OBJECTIVES OF PROGRAM/INTERVENTION

Adapt the PPE teaching methods to introduce in-house geriatrics faculty to an interactive teaching style and educate clinicians in geriatric content during a CME course.

DESCRIPTION OF PROGRAM/INTERVENTION

Geriatrics educational experts met weekly and a consensus was reached on a teaching model with participants forming two teams, competing in a Jeopardy game and discussing unfolding cases. The teaching format was piloted with 17 geriatrics medicine and psychiatry fellows. Feedback sessions were conducted immediately post training and modifications made to course materials and teaching format. A team of two geriatric and subspeciality faculty/fellow experts facilitated 20-person workshops on six topics (pain, cognitive impairment, depression, falls,CHF, urinary incontinence) as part of a CME course. Facilitator and participant satisfaction surveys were collected.

FINDINGS TO DATE

The modified curriculum emphasized increased facilitator-group interaction and provided faculty a new format to teach geriatrics CME. Preliminary participant survey data demonstrated a high level of satisfaction with the teaching style. In addition, workshop facilitators were enthusiastic about their experiences with the two-team approach and unfolding case study teaching style. Examples of the teaching tools will be shown.

KEY LESSONS LEARNED

A Jeopardy and unfolding cases engage both learners and faculty to teach geriatric content to practitioners in the setting of a CME course. While this method is faculty intensive, facilitators and learners were highly satisfied with the experience.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Examples of the teaching tools will be shown.

INTRODUCING THE MYERS-BRIGGS TYPE INVENTORY TO RESIDENTS DURING PSYCHOSOCIAL ROUNDS.R.S. Adler¹. ¹Mount Sinai School of Medicine, New York, NY. (Tracking ID #116906)

STATEMENT OF PROBLEM OR QUESTION

Understanding the concept of personality and its effect on the doctor-patient relationship is an important aspect of psychosocial training for internal medicine residents. The various personality traits, as defined by DSM IV, have negative associations for many residents which leads to difficulties in recognizing, tolerating, and adapting to the personality styles of patients. Can the concept of personality type be framed in positive terms and lead to greater acceptance of the inherent differences between doctors and their patients?

OBJECTIVES OF PROGRAM/INTERVENTION

To intoduce the Myers-Briggs Type Inventory (MBTI) to PGY 2's as a tool to understand their own personality type and enhance personal awareness of differences.

DESCRIPTION OF PROGRAM/INTERVENTION

Recognition of the traditional DSM IV personality traits is on on-going theme for PGY 2's in a well established psychosocial program taught in a small group setting for 150 internal medicine residents. As a pilot, three groups of PGY 2's were introduced to the MBTI, which classifies people into 4 personality types: guardians, artisans, idealists, and rationals. All types are valuable, but different from each other. All 16 residents in the three small groups volunteered to compete the self scored MBTI, to read the detailed description for their type, and to share the results with the other residents in their group. Of the 16 PGY 2's, 8 were women and 8 were men and comprised 43% of the 37 PGY 2's in the residency program.

FINDINGS TO DATE

Thirteen residents self classified as guardians, three as idealists, and none as artisans or rationals. The idealists were 2 female and 1 male resident. In the small group discussions, all residents indicated that the written descriptions generally matched their behavioral patterns, but without the negative feelings associated with the DSM IV personality schema. Since this was a pilot project, the use of the MBTI was not specifically evaluated although PGY 2's complete overall evaluations of the psychosocial program.

KEY LESSONS LEARNED

None of the residents had used the MBTI in the past. In this informal setting, they found it both interestng and useful for self understanding. The use of the MBTI will be expanded to all PGY 2's as another tool to foster acceptance of the differences between themselves and their patients. In addition, a specific evaluation of its use will be added.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING.

LESSONS LEARNED FROM A NEW MINI CLINICAL SKILLS ASSESSMENT FOR MEDICAL STUDENTS IN THE PRIMARY CARE CLERKSHIP.M.M. Green¹; J. Butter¹; G.J. Martin¹; G. Makoul¹. ¹Northwestern University, Chicago, IL. (Tracking ID #117373)

STATEMENT OF PROBLEM OR QUESTION

It is difficult to assess clinical skills (i.e.,communication, history taking, physical exam) in a consistent manner while students are on their clerkships.

OBJECTIVES OF PROGRAM/INTERVENTION

(1) Assess students' ability to perform a focused history and physical and to integrate findings into a write-up; (2) Evaluate students' ability to accomplish basic and difficult communication tasks; (3) Expose students to a clinical skills exam similar in format to the USMLE CSE.

DESCRIPTION OF PROGRAM/INTERVENTION

We developed a 2-case, SP-based, mini Clinical Skills Exam (CSE) for students on the Primary Care Clerkship. Students were instructed to take an appropriate history, conduct a focused physical examination, and write up their findings and diagnostic impression. One case involved a 22yo female patient presenting with right lower quadrant pain. Given the details of this case, a sexual history would be considered appropriate; the advanced communication topic was to conduct a sexual history with a reticent gay patient. The other case focused on a 50yo female with multiple risks for osteoporosis presenting with acute low back pain. All encounters were videotaped. Immediately after each encounter, the SPs completed a structured evlauation of students' communication and physical exam skills. After finishing both encounters, students conducted a self-assessment while watching their own videotapes. Faculty reviewed and graded write-ups using a structured form and criteria, and met with students individually to provide feedback. This mini-CSE was first implemented in July 2003.

FINDINGS TO DATE

To date, 77 students have completed the mini-CSE; their response to both the SP encounters and faculty feedback has been positive. In the adbominal pain case, SPs reported that 25% of students provided a rationale for a sexual history, and 39% made them feel comfortable in this part of the interview. 58% of the write-ups included a sexual history, most of which were superficial (i.e., patient was sexually active, at risk for pregnancy, or had a history of STDs) With the exception of deep abdominal palpation (60% performed correctly), nearly all students performed well on the physical exam. In the back pain case, both SP reports and student write ups indicated that only about half of the students performed an adequate back and neuro exam.

KEY LESSONS LEARNED

(1) This is a valuable addition to the curriculum and provides useful information for improvement of student skills. (2) Students need more focused instruction in how and when to perform sexual histories. (3) At this stage, some students have trouble integrating appropriate exam maneuvers into the context of the patient visit.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Video of student-SP encounter as well as sample assessment tools, to be displayed via computer.

M3/4 IDC: A NEW INTERDISICPLINARY CURRICULUM FOR THIRD- AND FOURTH-YEAR MEDICAL STUDENTS.D.R. Reifler¹; R.M. Golub¹. ¹Northwestern University, Chicago, IL. (Tracking ID #117227)

STATEMENT OF PROBLEM OR QUESTION

Northwestern's preclinical curriculum includes medical decision-making, communication skills, ethics, medical humanities, economics, and other interdisciplinary topics; until recently this curriculum formally ended after two years.

OBJECTIVES OF PROGRAM/INTERVENTION

To expand and integrate coverage of interdisciplinary topics into the clinical years.

DESCRIPTION OF PROGRAM/INTERVENTION

Beginning in '02–`03, we implemented a new M3/M4 Interdisciplinary Curriculum that includes six M3 units and one M4 unit. M3 units are 1) Medical Decision-Making (MDM); 2) Nutrition Skills; 3) Difficult Conversations/Communication Skills; 4) Ethical, Legal, and Social Implications of Medicine (ELSI) Conference; 5) Bench-to-Bedside Conference (BBC); and 6) Patient, Physician & Society III (PPS III, a medical humanities unit). In the M3 year students meet for four hours on Friday afternoons once a month. Attendance is required, and on any given Friday each student attends three classes. Sessions emphasize student leadership and participation. Content focuses on application to patients students take care of. For the M4 unit, PPS IV, students meet monthly for 90 minutes. Attendance is required, and students' college affiliations are preserved. Class sessions focus on medical humanities, health economics and their ethical implications, and teaching. Students write a personal reflection on each topic in preparation for class. They also complete a new M4 teaching selective.

FINDINGS TO DATE

Students rated components from 1 (poor) to 5 (excellent). Mean M3 scores after 3 months were as follows: MDM, 3.21; Nutrition, 3.41; ELSI, 3.5; Communication Skills, 3.0; BBC, 3.0; and PPS III, 3.6. Students struggle with leaving clerkships to attend class, but attendance has been excellent. Faculty evaluations have been very positive. Students rated PPS IV 3.1 overall in its first year. Comments ranged from highly complimentary to derogatory. Students wrote compelling stories based on personal experience and taught many subjects. They appreciated the regular chance to see classmates.

KEY LESSONS LEARNED

We successfully created a third- and fourth-year interdisciplinary curriculum that integrates topics emphasized in the preclinical curriculum with clinical learning. Current plans are to expand this curriculum.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Power-point slides and/or poster demonstrating students' work in the various phases of the course.

MD-PH.D. RE-ENTRY CURRICULUM DECREASES ANXIETY.L.N. Dyrbye¹; R. Tiegs¹. ¹Mayo Clinic, Rochester, MN. (Tracking ID #115839)

STATEMENT OF PROBLEM OR QUESTION

After acquiring considerable clinical knowledge and skills during the first two years of medical school, MD-Ph.D. candidates part ways with their MD-only colleagues and spend 3-6 years pursuing their Ph.D. degree. Upon return to the MD program, MD-Ph.D. students report significant anxiety about re-entering the clinical curriculum.

OBJECTIVES OF PROGRAM/INTERVENTION

We developed a re-entry program to: 1. Decrease the anxiety of MD-Ph.D. students returning to the MD degree program. 2. Improve the clinical skills and performance of MD-Ph.D. students since most MD-Ph.D. students are not able to perform at the level of their MD-only colleagues during the early clinical rotations. 3. Update MD-Ph.D. students on recent advances in the computer-based clinical applications.

DESCRIPTION OF PROGRAM/INTERVENTION

Immediately prior to returning to the Year III clerkships, MD-Ph.D. students now participate in a re-entry program consisting of 10 half-day sessions. The first session includes a review of history taking and physical examination skills, clinical reasoning/diagnostic skills, use of the computer-based clinical applications, and basic clinical therapeutics. The following nine sessions begin with a one-hour, interactive, case-based discussion of topics in internal medicine, pediatrics, and psychiatry. Other activities include a half-day session devoted to interviewing standardized patients with psychiatric problems and discussing differential diagnosis and psychopharmacology. Two half-days are spent in both an outpatient internal medicine and pediatric clinic. During these assignments, students take focused histories, perform physical examinations, present cases, and discuss patient management. In addition, each student completes an evaluation of two hospitalized patients, presents the cases to their preceptor, and receives formative feedback. For the final two half-days, students examine hospitalized patients with pre-defined physical findings and discuss the patients with their preceptors.

FINDINGS TO DATE

Participating students completed a pre and post-intervention survey. Students reported a decrease in their anxiety about returning to the clinical curriculum and increased confidence in taking histories, performing general physical examinations, generating differential diagnoses, presenting cases, and navigating the computerized record system.

KEY LESSONS LEARNED

A well-designed, intensive, student-centered, clinical experience helps MD-Ph.D. students become more confident in their ability to function effectively in the clinical setting and facilitates the transition from the laboratory to clinical medicine.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING.

NEEDS ASSESSMENT FOR A FACULTY DEVELOPMENT PROGRAM IN EVIDENCE BASED MEDICINE.C.M. Warde¹; L. Nicholson²; J.R. Boker³. ¹Long Beach Memorial Medical Center, Long Beach, CA; ²University of California, San Diego, La Jolla, CA; ³University of California, Irvine, Irvine, CA. (Tracking ID #116247)

STATEMENT OF PROBLEM OR QUESTION

Faculty clinicians are expected to teach and model evidence-based practice for medical students and residents, but frequently lack essential experience and skills in evidence-based medicine (EBM).

OBJECTIVES OF PROGRAM/INTERVENTION

To target learning needs, we conducted a needs assessment focusing on three areas considered necessary to achieve the overall goal of practicing and teaching EBM at the point of care. These are: 1) understanding of the evidence-based approach to health care; 2) knowledge and use of evidence-based computerized resources; and 3) skills in validity evaluation and result interpretation for common article types.

DESCRIPTION OF PROGRAM/INTERVENTION

A yearlong EBM faculty development program was initiated at two teaching hospitals—a university hospital and a university-affiliated community hospital. Thirty teaching faculty and opinion leaders were invited to participate. Each completed a two-part evaluation prior to the course: 1) a questionnaire to evaluate demographics, attitudes and exposure to EBM, computer literacy, and references used at the point of care; and 2) the previously validated Fresno Test of Evidence Based Medicine to examine EBM knowledge and skills.

FINDINGS TO DATE

Results of the two-part needs assessment revealed knowledge gaps in all three of the above objectives. For EBM approach to health care, 53% described their EBM knowledge as “fair” or “poor.” While greater than 70% reported asking focused clinical questions before making therapy decisions, participants demonstrated only 60% accuracy at building these questions. For use of computerized resources, 86% of the university hospital faculty but only 19% of the community hospital faculty reported at least weekly use of an EBM resource other than Medline. In literature evaluation skills, more than 80% could name the appropriate study design for comparing therapies, but fewer than half could define relative risk reduction or a significant confidence interval. Identified barriers for practicing point-of-care EBM included insufficient internet access and computer literacy.

KEY LESSONS LEARNED

Despite important teaching and leadership roles, our faculty subjects are deficient in EBM skills and resource utilization. Knowledge deficits and barriers described above will need to be overcome before point-of-care EBM can be practiced and thereby modeled for future clinicians.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

On-line access will be used to demonstrate clinical information searches using EBM internet resources, and teaching materials will be available to potential collaborators.

OBJECTIVE STRUCTURED CLINICAL EXAMS (OSCES) TEACH ABOUT SUBSTANCE ABUSE.S.J. Parish¹; M. Stein¹; E.K. Kachur²; M. Ramaswamy¹; J.H. Arnsten¹. ¹Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; ²Medical Education Development, New York, NY. (Tracking ID #116477)

STATEMENT OF PROBLEM OR QUESTION

Internists are commonly required to manage substance abuse disorders. OSCEs provide necessary skills practice by exposing trainees to standardized clinical scenarios and permitting individualized feedback.

OBJECTIVES OF PROGRAM/INTERVENTION

Our 5-station Substance Abuse OSCE is designed to teach competencies in addiction medicine, provide a performance-based assessment, and deliver feedback. The 3-hour OSCE is completed during a PGY3 ambulatory block, which includes didactic substance abuse instruction.

DESCRIPTION OF PROGRAM/INTERVENTION

Experts in primary care and addiction medicine constructed scenarios addressing a range of substance abuse disorders (heroin, cocaine, alcohol) and readiness to change stages (pre-contemplation to maintenance). At each station residents had 10 minutes to build rapport, assess, and manage a standardized patient (SP) with a faculty observer. Faculty were trained to use 17-item rating forms covering communication, assessment, management, general organization and overall performance; provide 5 minutes of feedback; and deliver teaching points. SPs provided a global satisfaction rating and verbal feedback. Residents assessed their overall station performance.

FINDINGS TO DATE

To date, 29 PGY3 residents have participated. All faculty and 90% of residents fully or partially agreed that the stations resembled real encounters, and 90% of both faculty and residents agreed that the OSCE presented a good cross-section of substance abuse problems. Residents were more skilled in general communication (mean = 3.3) than assessment (mean = 2.8) or management (mean = 2.7) (P < .0005 for both comparisons). Residents performed similarly on alcohol and cocaine/heroin stations, but a reliability coefficient of 0.4 (Cronbach's alpha) suggests a moderate level of station specificity. For global performance, correlation between faculty and SP ratings was 0.6 (P < .0005). Residents rated themselves lower than faculty (mean 2.5 v. 2.9, P < .0005). Residents reported they definitely received valuable feedback (72%), were helped to identify weaknesses (69%), and learned something new (66%). Faculty affirmed they learned new information about residents' skills (74%).

KEY LESSONS LEARNED

A substance abuse OSCE with immediate feedback is useful for teaching addiction medicine competencies. Assessment and management in this area are more challenging for residents than general communication skills.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Hand-outs of sample clinical scenarios and rating forms.

PATIENTS AS TEACHERS: A MODEL FOR TEACHING ATTITUDES AND SKILLS OF LONGITUDINAL DOCTOR/PATIENT RELATIONSHIPS.E. Scully¹; N. Angoff¹. ¹Yale University, New Haven, CT. (Tracking ID #117515)

STATEMENT OF PROBLEM OR QUESTION

Medicine is increasingly focused on outpatient care, shifting from acute management towards prevention and chronic care. Clinical training continues to emphasize inpatient medicine and brief contact with the acutely ill leaving the specific skills of longitudinal care largely underdeveloped.

OBJECTIVES OF PROGRAM/INTERVENTION

The elective integrates medical students into a relationship with both a preceptor and an HIV-infected patient for the duration of medical school with the following objectives: 1) understand the relevance of basic science to patient care, 2) develop an awareness of a patient's life, home, beliefs and values and how they affect illness and treatment decisions, and 3) develop communication skills in the sensitive areas of sex, illegal behaviors and death.

DESCRIPTION OF PROGRAM/INTERVENTION

Ten first year students were selected by essay applications and paired with a preceptor. Each pair determined the structure with the majority of students shadowing the preceptor through clinics until a patient was selected. Once a single patient was identified, the student followed their care through appointments with the AIDS clinic, other physicians and through hospitalizations. Each student carried a pager and acted as the patient's first contact in case of problems, and had clear strategies of contacting preceptors/covering attendings. Student-patient contact frequency varied and was supplemented by home visits, phone and email contact. The student group meets monthly during the academic year, providing a forum for students to discuss their often emotionally charged experiences with the feedback and support of their peers. These meetings also include informal lectures on relevant topics including end of life decisions, HIV and Hepatitis C co-infection, and the role of the chaplain in care relationships. The program aims for students to evolve from the role of “friend” to that of caregiver and in the later years, students assume more responsibility, performing history and physical exams and writing chart notes.

FINDINGS TO DATE

There have been ∼50 participants in the five years of the elective with evaluation through student questionnaires and informal survey of attendings and patients both of whom report that students enhance care. Student response has been extremely positive with the caveat that quality varies based on the particular student:preceptor relationship. Students specifically identify the early clinical exposure the elective allows, the singular quality of the longitudinal patient relationship, the development of communication skills and the experience of attempting to provide optimal care within the context of an individual's life.

KEY LESSONS LEARNED

Integrating a patient care experience throughout medical school allows early clinical exposure and uniquely longitudinal relationships.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING.

PERSONAL DIGITAL ASSISTANTS AT THE POINT OF CARE: A TRAINING PROGRAM FOR MEDICAL STUDENTS.A. Kho¹; S. Kripalani¹; D. Dressler¹; V. Akopov¹; Y. Cua¹; L. Difrancesco¹; N. Ilksoy¹; C. Iverson¹; J. Kleinbart¹; G. Margolias¹; J. Messler¹; C. Sam¹; N. Winawer¹; M.V. Williams¹. ¹Emory University, Atlanta, GA. (Tracking ID #116142)

STATEMENT OF PROBLEM OR QUESTION

Personal digital assistants (PDAs or handheld computers) allow physicians to rapidly access medication information, medical calculators, and decision support tools while providing patient care. However, most medical students currently receive no formal training in the use of these devices.

OBJECTIVES OF PROGRAM/INTERVENTION

(1) To increase medical student use of PDAs at the point of care, (2) to provide students with an electronic reference that addresses diseases commonly seen in inpatient Internal Medicine, and (3) to encourage an evidence-based approach to patient evaluation, treatment, and hospital discharge.

DESCRIPTION OF PROGRAM/INTERVENTION

The Emory Hospital Medicine Unit (EHMU) developed decision-support software and a series of PDA-based workshops that train medical students in the effective use of PDAs during their Internal Medicine clerkship. The workshops begin with an overview of PDAs, their medical applications, and existing software packages. Subsequent workshops use clinical cases to discuss common inpatient diseases, using PDA resources to guide students through the evaluation and treatment of the patient. The central feature of the curriculum consists of a set of nine evidence-based PDA software modules developed by EHMU physicians in close collaboration with a medical software developer. We chose the following topics based on their relevance to hospital medicine: acute coronary syndrome, asthma, community-acquired pneumonia, congestive heart failure, venous thromboembolic disease, chronic obstructive pulmonary disease, sickle cell pain crisis, diabetic ketoacidosis, and hypertensive crisis. Each module focuses on key steps in the diagnosis and management of the hospitalized patient. Each module also provides prognostic information, discharge criteria, recommended follow-up, as well as references, medical calculators, and “clinical pearls” that might be encountered on rounds. A companion website provides abstracts and full-text articles for additional reading.

FINDINGS TO DATE

We found that 88% of medical students used a PDA during their Internal Medicine rotation. Most (86%) of these students found the software modules somewhat useful to extremely useful in helping them learn about the evaluation and management of common inpatient illnesses.

KEY LESSONS LEARNED

Medical students are eager to use PDAs in clinical settings. An organized curriculum that includes discussion of medical PDA applications enhances the use of PDAs at the point of care.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

PDA, laptop computer.

PORTAL OF GERIATRIC ONLINE EDUCATION (POGOE).K. Denson¹; E. Vandenberg²; W. Lyons³. ¹Medical College of Wisconsin, Milwaukee, WI; ²Donald W. Reynolds/ADGAP, Omaha, NE; ³Donald W. Reynolds and ADGAP, Omaha, NE. (Tracking ID #117265)

STATEMENT OF PROBLEM OR QUESTION

Although the U.S. population of adults age 65 and over is predicted to double from 35 million in 2000 (12.4%) to 70 million (20.6%) by 2030, the number of academic geriatricians remains—and is projected to remain—insufficient to train the number of physicians who will be necessary to care for an aging U.S. population (IOM 1993; Ann Intern Med. 2003; 139:S607–S614).

OBJECTIVES OF PROGRAM/INTERVENTION

The Portal of Geriatric Online Geriatric Education (POGOe) has been designed to enhance physicians' ability to meet the healthcare needs of older adults by providing those interested in geriatrics education with a single source for high-quality educational products while, at the same time, providing a venue to aid clinician-educators in demonstrating their scholarship for promotion.

DESCRIPTION OF PROGRAM/INTERVENTION

POGOe is a new online clearinghouse that provides a single source for high-quality peer-reviewed educational products. Experts in an array of medical, communication, and educational fields reviewed educational interventions used to teach geriatrics to internal medicine residents and methods of educational evaluation, identified potential criteria, and came to a consensus on the criteria needed for product acceptance. POGOe is searchable by type of learner, content area, type of instruction and assessment used, and type of learning environment. Grantees of the Donald W. Reynolds Foundation and the American Association of Medical Colleges/John A Hartford Foundation produced many of the initial products; however, we encourage all to submit. Examples of interest to teaching internists include: CD-ROM virtual patient cases covering osteoarthritis, functional assessment, hearing and vision, and other geriatric concerns; a pocket card describing how to approach to older patients and common drug side effects; a home-visit curriculum combining Geriatrics and Palliative Care; a CD-ROM, Powerpoint and overhead product that can be used for case-based discussions of delirium in elderly ED patients; and Geri Pearl pocket cards for pain management, preoperative assessment, pressure ulcers, etc. POGOe is funded by a grant from the Donald W. Reynolds Foundation to the Association of Directors of Geriatric Academic Programs.

FINDINGS TO DATE

There are increasing numbers of products to teach geriatrics, however they can be difficult to access and are of undetermined quality. This is the first portal for accessing peer-reviewed geriatric educational materials. Thus far, evaluation has mainly been by user satisfaction surveys or changes in pre-post medical knowledge.

KEY LESSONS LEARNED

At this point in time, POGOe's peer review assures accuracy, clear educational learning objectives that should be able to be met by the product, pilot testing of the product with evaluation data, and, when appropriate, clear learner and teacher instruction materials. Many in the geriatrics clinician-educator community are developing competency-based evaluations for their educational products. As this occurs, it is likely that the requirements for acceptance to POGOe will change.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Powerpoint Presentation, Open Discussion, and will need a T-1 Line.

PRACTICE-BASED LEARNING: QUALITY IMPROVEMENT EDUCATION IN AN INTERNAL MEDICINE RESIDENCY PROGRAM. M.D. Virden¹; E. Rouf¹; N. Key¹; A. Charbonneau¹; E.E. Ellerbeck¹. ¹University of Kansas Medical Center, Kansas City, KS. (Tracking ID #116775)

STATEMENT OF PROBLEM OR QUESTION

ACGME (Accreditation Council for Graduate Medical Education) core competencies include practice-based learning and improvement, and systems-based practice—domains of knowledge that have traditionally been difficult to teach in graduate medical education. Practical introduction to and learning of these core competencies have the potential to improve healthcare quality.

OBJECTIVES OF PROGRAM/ INTERVENTION

Design a case study approach to: 1) introduce a set of quality improvement measures for analyzing practice experience, 2) identify potential barriers to implementing quality measures in the clinic, and, 3) propose solutions to address quality of care concerns.

DESCRIPTION OF PROGRAM/INTERVENTION

We introduced a series of quality improvement modules to address improvement of clinic practice using real-life data obtained via the participation of the residents' clinic in a statewide quality improvement project. During the initial module, residents compared their pneumococcal vaccination rates with those of benchmark practices. A series of questions and a faculty-facilitated discussion walked the residents through national standards for pneumococcal vaccination, and focused on interpretation of the clinic's performance, factors that might contribute to this performance, system changes that might lead to improved performance, and potential barriers to making these changes. A survey assessed residents' prior knowledge of quality improvement, and gathered their input on topics for development of future quality improvement learning modules.

FINDINGS TO DATE

Residents found this to be an engaging learning experience, which provided them with information not covered elsewhere in their training. Residents expressed interest in examining other measures such as diabetes services and cancer screening.

KEY LESSONS LEARNED

Residents had received little or no prior training in quality improvement during their residency program. We anticipate future quality improvement modules based on this model will help residents effectively learn such core competencies as practice-based learning and improvement, and systems-based practice.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Computer, PowerPoint, Q&A.

PROFESSIONALISM: THE FOUNDATION OF ALL COMPETENCIES AND THE FUTURE OF MEDICINE.W. Wiese¹; S. Eggly¹. ¹Wayne State University, Detroit, MI. (Tracking ID #117208)

STATEMENT OF PROBLEM OR QUESTION

As society places increasing demands on physicians to articulate and exemplify the principles of professionalism, residency programs face the difficulties inherent in defining, teaching and measuring this elusive notion. Our institution has addressed components of this competency through a web-based learning module and essay, followed by an interactive workshop, and evaluated with an OSCE.

OBJECTIVES OF PROGRAM/INTERVENTION

To provide a comprehensive template for teaching and evaluating professionalism.

DESCRIPTION OF PROGRAM/INTERVENTION

On the website, residents read definitions of what it means to be a professional physician. They respond in writing to three open-ended questions regarding their personal defenition as well as their experiences with outstanding examples of professionalism and breaches of professionalism. Responses are incorporated into an interactive workshop where residents are challenged to explore the factors that contribute to unprofessional behavior and how they will manage these factors in their careers. Residents' responses are turned into cases, and the residents are asked to identify factors that may have led to the unprofessional behavior, and ways to respond when witnessing this behavior. Finally, residents suggest realistic strategies to decrease the incidence of unprofessional behavior from a personal and systems perspectives. Residents' competence in professional behavior, communication and interpersonal skills, and systems-based practice are assessed by a four-station OSCE in which 1) they must apologize to a patient whom they prescribed the wrong medication, and respond to the patient's request to create new systems to prevent this from happening to other patients; 2) obtain a sexual history from a flirtatious patient; 3) screen for domestic violence and provide available resources to a depressed patient who is being battered at home; and 4) respectfully organize an interaction with a patient that rambles inappropriately.

FINDINGS TO DATE

Responses to the assignment have been thoughtful and led to provocative discussions of the factors influencing professional behavior. Documentation occurs in that trainee's responses are placed in their evaluation file. The OSCE is also rated using the SEGUE framework. In addition, residents get a CD with their interaction for self-reflection or discussion with their clinic preceptor.

KEY LESSONS LEARNED

This workshop has been demonstrated to be effective in facilitating reflection and discussion of professional physician behavior.The OSCE provides an excellent assessment tool of professionalism and other competencies.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

PROMOTING SUBSTANCE ABUSE EDUCATION AMONG GENERALISTS: THE CHIEF RESIDENT IMMERSION TRAINING (CRIT) PROGRAM.D. Alford¹; T.W. Clark²; J.H. Samet¹. ¹Boston Medical Center, Boston, MA; ²Health and Addictions Research, Inc, Boston, MA. (Tracking ID #116852)

STATEMENT OF PROBLEM OR QUESTION

Inadequate medical education about substance abuse.

OBJECTIVES OF PROGRAM/INTERVENTION

To increase Chief Residents' (CRs) interests, knowledge, and skills about substance abuse (SA) in order to facilitate teaching these issues to their trainees.

DESCRIPTION OF PROGRAM/INTERVENTION

We developed a 3-day, intensive Chief Resident Immersion Training (CRIT) program to teach state-of-the-art clinical knowledge in screening, diagnosis and management of SA disorders using case-based didactic presentations, small group workshops, skills practice sessions and site visits. Based on individual interests and course content, each CR designed an Action Plan (AP)—a project achievable during the first 4 months of their CR year that educates about SA screening, diagnosis and management. By means of pre- and post-program assessments, we evaluated CRIT's impact on a CR's knowledge, clinical practice, and teaching related to SA. We also assessed AP implementation.

FINDINGS TO DATE

We trained 40 CRs from 34 residency programs in 2 CRIT programs. Evaluation of the Year 1 cohort (n = 21) revealed the following: knowledge score—70% pre-CRIT, 82% post-CRIT; at 6 month follow up (n = 17/21; 81%), 35% were “more likely” and 59% were “much more likely” to incorporate SA content in their teaching; 71%“sometimes” or “usually” served as a SA resource for their students, house staff and faculty, compared to 18% pre-CRIT; and on average CRs reported percentage increases of the following SA clinical practices: screening (10%); referral (13%); and treatment (19%). Other 6 month findings included: average AP completion 48%; which resulted in new or expanded SA curriculum (47%); new SA-dedicated lecture or teaching event (59%); and development of protocols for SA screening (24%), SA treatment (29%), and links to SA treatment organizations (29%). Program evaluation limitations include subject self-report, potential desirability response bias, study size and absence of a non-intervention control group.

KEY LESSONS LEARNED

The Chief Resident Immersion Training (CRIT) program in Addiction Medicine for incoming Chief Residents increased knowledge, clinical practice, and teaching related to SA. The CRIT model is an effective educational approach for disseminating SA and possibly other content expertise to medical trainees.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING.

PROPOSED COMPETENCY PREREQUISITES FOR ENTERING THE CORE CLINICAL CLERKSHIPS.A. Goroll¹; E.B. Bass²; M. Kuzma³; T. Defer⁴. ¹Massachusetts General Hospital, Boston, MA; ²Johns Hopkins University, Baltimore, MD; ³Drexel University, Philadelphia, PA; ⁴Washington University in St. Louis, St. Louis, MO. (Tracking ID #117125)

STATEMENT OF PROBLEM OR QUESTION

Medical schools are reexamining students' preparation for the core clinical clerkships, especially in view of the renewed emphasis on core clinical competencies (e.g., the ACGME competency agenda).

OBJECTIVES OF PROGRAM/INTERVENTION

Our objectives were to 1) establish a consensus among representatives of family medicine, internal medicine, and pediatrics regarding the level of clinical competencies that students should attain prior to beginning the core clinical clerkships and 2) to develop a new preclerkship curriculum resource that educators can use to strengthen training in the identified fundamental competencies.

DESCRIPTION OF PROGRAM/INTERVENTION

Through a contract with the Health Resources and Services Administration, the Society of General Internal Medicine, the Clerkship Directors of Internal Medicine, and the Ambulatory Pediatric Association joined with the Society of Teachers of Family Medicine to assemble a Preclerkship Collaborative Workgroup. The Workgroup consisted of teams of experts in clinical teaching and curriculum design from each of the participating specialties. After reviewing the literature on clinical competency training and the results of an independent survey of core clerkship directors in family medicine, internal medicine, pediatrics, gynecology, surgery, and psychiatry, the Workgroup developed a consensus document specifying the prerequisite competency agenda essential to effective learning in the core clerkships. It elucidates six priority areas for reforming preclinical medical education: interviewing and physical examination skills, communication, professionalism, lifecycle and self-awareness, probabilistic thinking, and systems of care. The Workgroup then designed a curriculum guide organized in terms of the ACGME competencies to serve as a resource for curriculum planners. The guide specifies learning objectives for the competencies pertinent to preparation for the core clerkships and provides teaching materials and suggestions for learning methods, and assessment.

FINDINGS TO DATE

The Workgroup has presented draft elements of the resource guide and the priority area document at national meetings of numerous organizations including the AAMC, STFM, CDIM, AAP, and SGIM. Feedback generally has been very positive, although some curriculum leaders have expressed concern about the needed resources and scant curriculum time available.

KEY LESSONS LEARNED

We have learned that educators across disciplines have remarkable agreement about the importance of the prerequisite competencies identified in the curriculum resource. Any successful reform attempt will need to address the resource and time issues specifically and creatively. The Workgroup's curriculum resource should enhance the ability of educators to reform preclerkship training and build on the ACGME competency initiative.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

A poster will outline the contents of the curriculum resource materials, and will give information on how to access the resource document.

RESIDENT REVUE: RESIDENT JOURNAL TO PROMOTE PROFESSIONALISM AND PBLI.J.M. Golbin¹; J. Andrieni¹; J. Bonheur¹; J.M. Bratcher¹; S. Fields¹. ¹Lenox Hill Hospital, New York, NY. (Tracking ID #116148)

STATEMENT OF PROBLEM OR QUESTION

Medical education in traditional Internal Medicine residency programs is achieved via several modalities: morning report, teaching/work rounds, conferences, and independent research. This process can be enhanced with the use of a resident publication that encourages discussion of medical cases, unique EKG/radiographic findings, economic and ethical considerations, and other creative projects.

OBJECTIVES OF PROGRAM/INTERVENTION

1) Promotion of residents' academic work; 2) Establishment of an outlet for personal creativity; 3) Advancement of ACGME core competencies of Professionalism and PBLI.

DESCRIPTION OF PROGRAM/INTERVENTION

Resident Revue (RR): The Medical Journal of Lenox Hill Hospital was established in 1998 by a group of residents who sought to create an academic newsletter written and edited solely by and for Internal Medicine residents. Initial features included a case presentation, a review of a medical topic, a review of a specific medication, and an interesting EKG/radiographic finding. RR evolved into a glossy magazine with approximately three editions per year. RR was further expanded with opportunities to write articles for the journal as scholarly activity in the new ambulatory medicine curriculum via an ACGME grant for “Resident Driven Graduate Medical Education.” Resident submissions included articles on medical economics and medical ethics, creative writing of patient encounters, and artistic expression in medicine. RR is peer-reviewed by an editorial committee composed of IM residents, Chief Residents, and the faculty advisor.

FINDINGS TO DATE

Publications in RR have become poster presentations at national meetings. Faculty, medical students, and administration have taken an interest in this communication vehicle for IM resident work. Upcoming goals include measuring the development of resident writing and editorial abilities in a scholarly publication. Furthermore, the editorial committee will examine the change in resident practice patterns from evidence-based medicine articles provided by RR.

KEY LESSONS LEARNED

Residents are exposed to a wider breadth of medical knowledge due to the variety of cases presented in RR. Due to the creative opportunities in the journal, residents' humanistic qualities can be more clearly elucidated. RR promotes continuous professional development and increases residents' skill in publication submission and academic writing.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Copies of RR will be displayed and distributed during the presentation.

SOCIAL ACTIVISM IN MEDICINE: A NOVEL APPROACH TO INCORPORATING SOCIAL RESPONSIBILITY INTO UNDERGRADUATE MEDICAL EDUCATION.B. Moyers¹; K. Luman¹; J. Wagner¹; A. Fernandez¹; S. Jain¹. ¹University of California, San Francisco, CA. (Tracking ID #116168)

STATEMENT OF PROBLEM OR QUESTION

The AAMC Medical School Objectives Project outlined learning objectives for undergraduate medical education to provide physicians-in-training with the attributes necessary to meet their individual and collective responsibilities to society. One of these critical areas includes instilling and cultivating a sense of social responsibility in medical students, with specific learning objectives in the areas of altruism and duty. However, it has been difficult to incorporate those objectives into traditional medical school curriculum.

OBJECTIVES OF PROGRAM/INTERVENTION

Our goal was to introduce medical students to the concept of social responsibility and activism by creating an elective that promotes the discussion of important social issues and the formation of mentoring relationships between students and physicians who have incorporated health advocacy, community education, and social activism into their professional lives.

DESCRIPTION OF PROGRAM/INTERVENTION

The Social Activism in Medicine elective is a year-long course that meets monthly and has been offered for two years. Each ninety-minute session is led by a socially active physician. Lecturers speak to their work within the context of a particular societal problem and how their training led them to incorporate activism into their careers. Titles of lectures have included “Care of the Disenfranchised,”“Political Activism, Mental Health, and Human Rights,” and “Health Literacy.” The timing of each topic parallels the subject matter of the core curriculum; for example, the talk on global tobacco control initiatives occurs when students are learning pulmonary physiology and the effects of cigarette smoke.

FINDINGS TO DATE

Students have been enthusiastic about the elective. They have appreciated the chance to learn from physicians who have brought about changes to improve the health of their communities. Students have rated the elective very favorably and remarked on its strong inspirational value. In written evalautions, all students have agreed or strongly agreed that “this lecture motivated me to incorporate activism into my future career” and that “this material should be incorporated into the core curriculum.”

KEY LESSONS LEARNED

The Social Activism in Medicine elective provides students with a unique opportunity to meet with and learn from socially active physicians. We hope that ongoing mentoring relationships develop and that students learn specific ways to become involved in their communities as social activists. By designing the elective to parallel the core curriculum, we hope that students see links to the traditional medical school curriculum. Further efforts will include trying to incorporate parts of this material in the core curriculum for all students.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

TARGETED ACADEMIC DETAILING TO REDUCE SUBOPTIMAL ANTIBIOTIC USE IN A TEACHING HOSPITAL.C.A. Morris¹; M.A. Fischer¹; J. Avorn¹. ¹Brigham and Women's Hospital, Boston, MA. (Tracking ID #116800)

STATEMENT OF PROBLEM OR QUESTION

Overuse of antibiotics can increase costs, lead to adverse drug reactions, and promote bacterial resistance. Prior research has demonstrated that academic detailing can effectively change prescribing behavior, though this approach has been used less often in acute care settings.

OBJECTIVES OF PROGRAM/INTERVENTION

1) To promote the appropriate use of three commonly used antibiotics for patients on the medical services of a large teaching hospital; 2) To implement academic detailing in a real-time intervention to educate resident physicians about better antibiotic prescribing; 3) To collect data on why certain antimicrobials are misused and to identify trends in suboptimal prescribing.

DESCRIPTION OF PROGRAM/INTERVENTION

Research assistants extract orders for vancomycin, levofloxacin and ceftazidime daily from the hospital's electronic order entry database; these are provided to several infectious diseases fellows working as academic detailers. The detailers review each case and if use seems suboptimal, contact the ordering housestaff for a one-on-one conversation to deliver a focused educational message based on the particular order. The rationale for the drug is discussed and alternatives strategies are proposed, when appropriate. The educator completes a brief online data form to record information about the encounter. Trends of optimal and suboptimal prescribing are fed back to the housestaff.

FINDINGS TO DATE

During 66 detailing days in 2003, 421 orders were reviewed. Common clinical situations in which levofloxacin was suboptimally prescribed included asymptomatic bacteriuria and as continuing therapy for patients transferred from other institutions while already receiving levofloxacin. Vancomycin was potentially overused in patients with coagulase negative Staphylococcus species bacteremia, and with skin and soft tissue infections. Ceftazidime was potentially overused in patients with suspected pneumonia, or as empiric coverage for presumed intraabdominal infection. Analysis of the operationalized program found that it has been well received by medical residents.

KEY LESSONS LEARNED

There are common and consistent patterns of antibiotic use and misuse, which can be targeted as topics for broader educational initiatives. Academic detailing can be successfully implemented as part of an ongoing quality improvement and physician education program. Resident physicians are eager to receive this timely and focused teaching.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

1) Online collection of data about the detailing encounter; 2) Educational handouts used by academic detailers, available in print, via hospital intranet and on personal digital assistants (PDAs).

TEACHING ADDICTION MEDICINE IN A CLINICAL CLERKSHIP OF COMMUNITY MEDICINE: MEDICAL STUDENTS LIKE IT!J. Humair¹; B. Broers¹; P. Gache¹. ¹Department of Community Medicine, Geneva University Hospital, Geneva. (Tracking ID #116621)

STATEMENT OF PROBLEM OR QUESTION

Although use of tobacco. alcohol and illicit drugs are major public health problems, teaching of addiction medicine is very limited in curricula of most medical schools.

OBJECTIVES OF PROGRAM/INTERVENTION

Since 1998, in 4th and 5th years of the undergraduate curriculum in Geneva, medical students attend a clinical clerkship in community medicine including teaching activities in addiction medicine with the following objectives: (1) to identify problematic use of tobacco, alcohol and illicit drugs in primary care; (2) to experience clinical contact with patients having these 3 major addictions; (3) to know the major therapeutic strategies for patients with addictive disorders.

DESCRIPTION OF PROGRAM/INTERVENTION

This 4-week clerkship organized for rotating groups of 8-12 students includes clinical and didactic activities in primary care. Regarding addiction medicine, students spend 2 full days in one of 4 substance abuse units providing multidisciplinary care to patients with either alcohol or illicit drug addiction. They attend 16 hours of interactive teaching including: (1) two problem solving tutorials about detection and management of alcohol and heroin abuse; (2) a workshop based on clinical cases about tobacco use and stage-matched smoking cessation interventions; (3) a workshop using role plays to teach motivational interviewing and counseling strategies facilitating behavior change.

FINDINGS TO DATE

We evaluated on a 5-point scale the satisfaction of this clerkship among 135 students in 2001–2003. Students rated clinical activities in both drug and alcohol abuse units with high mean scores for learning new knowledge (4.5 and 4.2 respectively) and supervision (4.5 and 4.4). Mean scores for achievement of objectives, relevance of activities and integration in the clerkship were high for both workshops on smoking cessation (4.5 for 3 criteria) and motivational interviewing (4.0, 3.9 and 4.0 respectively). Students wished to lengthen this program as it is the only significant exposure to clinical situations and public health problems related to addictions.

KEY LESSONS LEARNED

We successfully integrated 32 hours of teaching on addiction medicine in a community medicine clerkship. Students expressed a high level of satisfaction with clinical and interactive teaching dealing with addictions. Further research should explore whether teaching addiction medicine in medical school improves physicians' competences, clinical care and public health outcomes.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Examples of problem-solving script, clinical vignette and role play will be demonstrated.

TEACHING BREAKING BAD NEWS WITH CANCER PATIENTS.D.L. Stevens¹; S. Zabar¹; K. Hanley¹; B.P. Dreyer¹; A.L. Kalet¹; M. Lipkin¹. ¹New York University, New York, NY. (Tracking ID #117510)

STATEMENT OF PROBLEM OR QUESTION

Breaking bad news is a among the most dreaded of all the roles of the physician, but a doctor's skill in breaking bad news has been shown to have lasting effects on a patient's ability to cope with the new diagnosis. Future physicians need both the basic skills of breaking bad news as well as an appreciation of the profound impact this singular moment has in the lives of patients.

OBJECTIVES OF PROGRAM/INTERVENTION

We sought to develop and pilot a workshop for 1st year medical students that combined 1) an evidence based outline of the skills of breaking bad news, 2) a small group discussion with a patient about his/her experiences receiving a life threatening diagnosis and 3) practice breaking bad news using role play.

DESCRIPTION OF PROGRAM/INTERVENTION

As part of NYU's Physician, Patient and Society course, we developed and implemented a 2 hour small group seminar (8 students, 2 faculty members per group) for all 160 1st year students. A pilot group (4 of 20 small groups) were joined by patient-teachers—people in active treatment for cancer. Patient-teachers were prepared for their roles in advance and started the seminar off by discussing their own experiences in receiving bad news and the effect of the experience on their subsequent adjustment to living with a life threatening illness. Seminar faculty then led a discussion about the specific steps and skills involved in breaking bad news in which the patient-teacher was invited to compare this teaching to his/her own experiences. Students then broke off into pairs and practiced delivering a new diagnosis of hypertension in 2 role play cases. Groups that did not have a patient-teacher join them followed a similar format, but spent more time discussing the seminar faculty's experiences breaking bad news.

FINDINGS TO DATE

Students reported appreciating the opportunity to focus on the task of breaking bad news. Both students and faculty in the pilot groups reported that the presence of the patient-teacher made the learning experience much more compelling. Patient-teachers also found the experience to be postive, and all 4 agreed to return as patient-teachers when asked again 12 months later.

KEY LESSONS LEARNED

First year medical students are receptive and enthusiastic about learning to become skilled at breaking bad news. The presence of a patient-teacher who shares real experiences receiving and coping with bad news greatly added to both students' and faculty's satisfaction with the educational value of the seminar.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster outlining content/structure of workshop; Sample student handouts on breaking bad news; Copies of role play scenarios.

TEACHING CHRONIC ILLNESS CARE UTILIZING LEARNER-LED QUALITY IMPROVEMENT PROJECTS AND INTERPROFESSIONAL EXPERIENCES.R.B. Baron¹; S. Janson¹; M. Cooke¹; L. Kroon¹; K. Julian¹; A.M. Leeds¹; M.B. Potter¹; E. Wade¹; R.J. Rushakoff¹. ¹University of California, San Francisco, San Francisco, CA. (Tracking ID #117278)

STATEMENT OF PROBLEM OR QUESTION

Current medical practice demands that practitioners be skilled in chronic illness care.

OBJECTIVES OF PROGRAM/INTERVENTION

We developed a curriculum for primary care medicine residents, nursing and pharmacy students to 1) increase knowledge and skills in quality improvement techniques, 2) improve attitudes towards interprofessional care and 3) to teach the principles of chronic illness care.

DESCRIPTION OF PROGRAM/INTERVENTION

Primary care residents (n = 42), adult nurse practitioner students (n = 25) and pharmacy students (n = 30) were assigned concurrent morning continuity clinics to care for assigned patients with diabetes mellitus. Each session began with a 90-minute quality improvement conference. Learners were provided with a registry of their patients with diabetes and current patient outcomes. Working in interprofessional teams, learners were asked to design short-cycle quality improvement projects. Revised registry data was provided bi-monthly. Following the weekly conference, patients were seen by the interprofessional teams of providers.

FINDINGS TO DATE

Learners developed a wide variety of quality improvement projects addressing multiple aspects of chronic illness care. Learners announced the program by mail in three languages and contacted patients with abnormal HbA1c, patients without a recent eye exam or with elevated lipids or blood pressure. Several projects addressed the delivery service design and organization of health care: standing orders for blood tests were created, referral forms were eliminated for eye clinic visits, and group visits were initiated (glucometer training, self-management, nutrition). Projects were also aimed at patient self-management and community resources: goal-setting forms were developed and used, and several resource manuals were compiled and distributed (exercise resources, podiatrists, support groups). Projects also addressed decision support and clinical information systems: prevention reminder forms were revised and new forms were developed to support blood pressure management. After one year, 85% of learners rated their knowledge of the chronic care model as good to excellent and 83% of learners predicted a good to excellent likelihood they will apply new knowledge, skills and attitudes into their clinical practice.

KEY LESSONS LEARNED

Interprofessional, learner-led quality improvement projects are an effective technique for teaching chronic illness care to internal medicine residents and nursing and pharmacy students and are likely to impact their future practice.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Oral presentation or poster and supporting materials.

TEACHING MEDICAL RESIDENTS ABOUT PERSONAL FINANCE.G. Dhaliwal¹. ¹University of California, San Francisco, San Francisco, CA. (Tracking ID #115106)

STATEMENT OF PROBLEM OR QUESTION

Most resident physicians are financially illiterate and begin their careers at a substantial financial disadvantage compared to their college-educated peers (due to a decade-long year delay in receiving full salaries and escalating educational debt). Studies have cited physicians' financial concerns as an important cause of burnout, stress, and career dissatisfaction and have called for education in this area. A small number of residency programs teach financial matters such as practice management, managed care, and health care economics, but personal finance education is lacking. Residents' baseline knowledge of personal finance and investing and their attitudes toward receiving such education is unknown.

OBJECTIVES OF PROGRAM/INTERVENTION

To educate residents about the basics of personal finance.

DESCRIPTION OF PROGRAM/INTERVENTION

During their outpatient rotation, interns attend one 2 hour session that provides an overview of personal finance—income and spending, debt management, taxes, insurance, and retirement savings (special emphasis). Before the lecture, interns take the 2002 Vanguard/Money Magazine Investor Literacy Test. The average score of 1,000 randomly selected American investors was 40%. The financial news media and the test administrators regarded these results as a reflection of the poor financial literacy of most Americans. A post-session survey (questions outlined below) is administered.

FINDINGS TO DATE

The average score of the interns (n=36) on the Literacy Test was 39%, below that of college-educated investors (45%), but higher than subgroups which correspond to the typical resident: under age 35 (34%) and inexperienced investors (34%). The survey was administered on using a Likert scale where 1 =“strongly disagree” and 5 = “strongly agree.” Average scores are reported in parentheses. Most respondents disagreed (1.7) with the statement, “I have adequate knowledge of personal finance.” 86% have their pre-enrolled 401(k) from one hospital in a (default) savings account, and 72% have not enrolled in the 401(k) at another hospital. Attitudes were also assessed: “This session on personal finances was valuable.” (5.0) / “It is worthwhile to replace a medical talk with a personal finances lecture during this rotation.” (5.0) / “After this session I plan to make changes to my two 401(k) accounts.” (4.9) / “After this session I have a better understanding of income, social security, and other taxes and how they affect my paycheck and finances.” (4.7) Conclusion: Residents' knowledge of personal finance and investing is poor, but commensurate with the average American investor. A single session on personal finance is highly regarded and welcomed by the residents and can modify their financial decisions.

KEY LESSONS LEARNED:

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

TEACHING MEDICAL STUDENTS THE ASSESSMENT OF SUBSTANCE ABUSE WHEN EVALUATING PATIENTS DURING THEIR PRIMARY CARE CLERKSHIP.A. Wilk¹; S.G. Chheda². ¹University of Wisconsin-Madison, Madison, WI; ²University of Wisconsin Medical School-Madison, Madison, WI. (Tracking ID #116731)

STATEMENT OF PROBLEM OR QUESTION

In Healthy People 2,010, addressing substance abuse is seen as an important strategy for improving the nation's health. However, primary care physicians do not identify and diagnose substance abuse with the same degree of accuracy as they do other preventable medical conditions.

OBJECTIVES OF PROGRAM/ INTERVENTION

The purpose of the study was to assess third-year medical students' knowledge and skills in screening and counseling patients with tobacco and alcohol use before and after an initial one and one-half hour case-based educational intervention and a required 8-week primary care clinical clerkship.

DESCRIPTION OF PROGRAM/ INTERVENTION

The educational intervention is one and one-half hour case-based, interactive learning session during the students' 1-day orientation at the start of their eight-week primary care clerkship rotation. The case is a 43 y.o. patient presenting with the common complaint of abdominal pain with a significant history of heavy alcohol use.

FINDINGS TO DATE

A questionnaire was developed to assess self-reported substance abuse knowledge, attitude and skills of medical students. A pretest—posttest design was used to assess proportional differences in medical student performance. Proportional differences were analyzed by chi-square analysis. Total number of medical students was 21 during the first 8-week clerkship for the time period of July to August 2003. There was an overall trend in greater proportions of medical students performing tobacco and alcohol use screening after their 8-week primary care clerkship (absolute changes of 16% and 20%, P = .13 and 0.07). Student performance in counseling patients about tobacco cessation and safe alcohol use significantly improved 34% and 40% respectively, P < .05. Though improvements in identifying the CAGE questionnaire were not significantly different before and after the educational intervention and 8-week clerkship, the accurate interpretation did significantly improve (60% absolute change, P < .01).

KEY LESSONS LEARNED

Medical students reported greater performance in substance use screening and counseling after a one and one-half hour educational intervention and the completion of an 8-week primary care clerkship. We believe that medical students' greater performance and knowledge in substance use screening and counseling reflect a brief interactive educational intervention followed by 8 weeks of supervised outpatient clinical management of common medical conditions.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

“TEACHING PATIENTS” PROVIDE EFFICIENT, STANDARDIZED AND WELL-LIKED PHYSICAL EXAM SKILLS TRAINING.C.B. Aamodt¹; D.W. Virtue¹; R.A. Dahlberg¹. ¹University of Kansas, Kansas City, KS. (Tracking ID #115735)

STATEMENT OF PROBLEM OR QUESTION

Traditionally, first- and second-year medical students learn physical exam skills by practicing on fellow students in small groups led by clinicians. This has several potential drawbacks, including emotional discomfort for the students, variability in the skills emphasized by different clinicians, and extensive use of scarce faculty time.

OBJECTIVES OF PROGRAM/INTERVENTION

To address each of these potential limitations of the traditional approach, we developed a “teaching patient” program, in which non-clinicians with previous experience as standardized patients became “teaching patients.”

DESCRIPTION OF PROGRAM/INTERVENTION

A faculty general internist (the course director for the Clinical Skills course) taught physical exam skills to a single trainer who then taught 10 teaching patients (TP's). After the trainer's teaching session, the course director clarified and refined the teaching patients' physical exam skills. Following a lecture focusing on a specific component of the exam (e.g., HEENT, cardiovascular), each TP worked with a group of five students, each of whom performed that part of the physical exam. The TP guided students through the exams, reassured students about the level of discomfort involved, and provided immediate feedback regarding deviations from the standardized approach. One or two clinicians floated from room to room to answer questions and refine skills.

FINDINGS TO DATE

Based on a five point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree) over 97% of students agreed that this was a good learning experience. Over 95% indicated that their physical exam skills had improved. Several students commented that they preferred examining teaching patients to examining each other.

KEY LESSONS LEARNED

a) Because there was turnover in teaching patients, developing an “expert TP” was a valuable step, since it avoided constant demands on the course director to teach new TP's. b) Despite identical training, TP's varied in their teaching skill, so ongoing oversight was necessary. However, fewer clinicians were required when TP's were involved than with the traditional model. c) Students may be more concerned about examining one another than is commonly realized, since we received spontaneous comments about this even though we made no specific inquiry.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

To demonstrate our techniques, we will show videotapes of training techniques, students interacting with teaching patients and clinicians helping to refine techniques. We will provide handouts with detailed information about TP compensation, motivation and background, our TP instruction manual, and student evaluation form.

TEACHING PSYCHIATRIC MEDICINE TO INTERNAL MEDICINE RESIDENTS: AN INTEGRATED TEACHING MODEL.T.E. Vettese¹; D. Nistor². ¹St. Joseph Mercy Hospital, Ypsilanti, MI; ²St. Joseph Mercy Hospital, Ann Arbor, MI. (Tracking ID #115539)

STATEMENT OF PROBLEM OR QUESTION

The high incidence and prevalence of psychiatric disorders in medical patients in combination with a critical shortage of psychiatrists makes it vital that primary care residency training programs develop curricula that will teach future primary care physicians basic psychiatric care as well as coordination of care with psychiatrists and other mental health professionals.

OBJECTIVES OF PROGRAM/INTERVENTION

1) Teach internal medicine residents to diagnose and manage psychiatric disorders encountered in the primary care setting. 2) Promote a biopsychosocial model of disease.

DESCRIPTION OF PROGRAM/INTERVENTION

Our integrated educational model involves our residents indentifying patients in their continuity clinic patient panel that would benefit from psychiatric evaluation. A referral is then made to our liaison psychiatrist. The psychiatrist and a third year medical resident assigned to an ambulatory block month rotate through the clinic 1–2 half days each week. This resident, under direct supervision of the psychiatrist, conducts a psychiatric assessment on referred patients. The attending psychiatrist provides the resident education regarding diagnosis, treatment and follow-up of the psychiatric disorder as well as direct feedback regarding interviewing and communication skills. The diagnosis and management plan is communicated jointly to the patient. The psychiatrist and the rotating resident provide recommendations to the patient's primary care resident regarding longitudinal managment. The psychiatrist is available for up to three follow-up assessments.

FINDINGS TO DATE

Resident evaluations of our integrated psychiatry experience have been excellent. Our internal medicine residents feel that they have gained increased knowledge in the area of psychiatry and that the information gained will be highly relevant to the practice setting. Additional evaluation measures including pre- and post-tests to formally assess knowledge acquistion and patient satisfaction surveys will also be implemented. Additionally, this experience has been helpful to evaluate and provide feedback to residents on communciation and interviewing skills.

KEY LESSONS LEARNED:

An integrated psychiatry rotation can effectively teach internal medicine residents to diagnose, manage and coordinate care of psychiatric disorders in the outpatient setting and can serve as an important evaluation tool.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster and handouts.

TEACHING RESIDENTS PATIENT CENTERED CHRONIC ILLNESS CARE IN THE AMBULATORY SETTING: AN INTERACTIVE CURRICULUM.M. Nadkarni¹; C. Westley¹; C.L. Engelhard¹; J. Green-Pastors¹; J.T. Saunders¹; J.D. Voss¹. ¹University of Virginia, Charlottesville, VA. (Tracking ID #117360)

STATEMENT OF PROBLEM OR QUESTION

Residents receive little training in effective methods for managing patients with chronic illnesses and may not practice patient-centered, systems-based care.

OBJECTIVES OF PROGRAM/ INTERVENTION

This curriculum was designed to 1) Introduce concepts of ICIC chronic care model and patient-centered care 2) Improve resident skills in systems-based care 3) Help residents gain a greater understanding of patient barriers in managing chronic illness to enhance provision of patient-centered care.

DESCRIPTION OF PROGRAM/ INTERVENTION

We implemented a 12-hour interactive small group curriculum for all internal medicine interns during their ambulatory block. Four 1/2 day seminars included: 1. Introduction to the ICIC Chronic Care Model and systems-based care. 2. “Systems Walk” by trainees to replicate the patients' experience at a clinic visit 3. Diabetes Patient Self Simulation in which interns spent 72 hours living as a “diabetic patient”. 4) Micro and macroeconomics in the Health Care System as it affects provision of care to patients with chronic illnesses. 5) Patient-centered interviewing training

FINDINGS TO DATE

22 of 26 interns have completed the curriculum.Intern's evaluations indicate they feel more prepared to manage patients with chronic illnesses, better understand barriers to patients with chronic illnesses receiving excellent care, and better understand differences in managing patients with acute versus chronic medical problems. Interns also expressed a better understanding of the effect of systems based interventions on provision of care.

KEY LESSONS LEARNED

1) Many interns lack knowledge of the principles of sytems-based care and differences in managing patients with chronic versus acute medical problems. 2) Simple interactive techniques effectively highlight barriers to excellent patient care and illustrate improved approaches to patient-centered, systems based care. 3) Having interns experiencee life through the eyes of a diabetic patient can lead to them to profound insights about the difficulties patients may experience in self care. These insights may lead to a more patient-centered approach when they care for patients in the continuity clinic setting.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster, curriculum description ( handout) If desired, a powerpoint presentation of some components of the curriculum.

TEACHING RESIDENTS TO TEACH: A MINI-FELLOWSHIP TO IMPROVE TEACHING SKILLS AND ENCOURAGE CAREERS IN ACADEMIC MEDICINE.K. Julian¹; M.M. Wamsley¹; M. Vener¹. ¹University of California, San Francisco, San Francisco, CA. (Tracking ID #115845)

STATEMENT OF PROBLEM OR QUESTION

Residents in the core clinical training programs have primary responsibility for teaching medical students on the inpatient wards. Studies have estimated that residents spend up to 20% of their time on teaching activities, regardless of their department or future career plans (Greenberg LW, et al. Teaching in the clinical setting: Factors influencing residents' perceptions, confidence and behavior. Med Educ 1984;18:360–5). Despite residents' significant teaching responsibilities, most receive no formal instruction on how to teach effectively.

OBJECTIVES OF PROGRAM/INTERVENTION

1) To create a resident teaching fellowship for a group of multi-disciplinary residents. 2) To give residents formal instruction on how to teach effectively. 3) To provide residents with practical leadership skills. 4) To guide residents in completion of an educational scholarly project.

DESCRIPTION OF PROGRAM/INTERVENTION

The Resident Teaching Fellowship is a six-month fellowship for selected mid-level residents from core clinical departments. Twelve participants meet six hours each month. Course content includes instruction on creating a positive learning climate, bedside teaching, small-group teaching, large-group presentations, feedback and evaluation, leadership skills, and assessing problem learners. The curriculum is geared towards a multi-disciplinary group of learners and utilizes didactic lectures, small-group discussion, role-play, and reflection on videotaped scenarios.

FINDINGS TO DATE

We piloted this fellowship this year with internal medicine, family practice, pediatrics, obstetrics/gynecology and orthopedic surgery residents. We hope to expand this fellowship to psychiatry, general surgery, and neurology residents this next year. Resident response to the fellowship has been uniformly positive. We have developed a pre-post self-efficacy evaluation as well as a pre-post teaching self-assessment evaluation form. We are looking for an increase in resident's confidence in their teaching skills and an increase in utilization of specific teaching microskills. Results from this data analysis will be forthcoming.

KEY LESSONS LEARNED

Residents in all specialties are eager to improve their teaching skills. A successful teaching curriculum requires didactic instruction, teaching “practicum”, and small-group reflection. Institutional support for teaching curriculum is mandatory for successful course implementation.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster presentation including sample curricular materials and program schedule.

TEACHING STUDENTS ABOUT MANAGING PATIENT CARE IN AN AMBULATORY CONTINUITY CLINIC.M. Stellini¹; S. Popp¹; K. Ling-Mcgeorge¹; R.R. Frank¹. ¹Wayne State University, Detroit, MI. (Tracking ID #116592)

STATEMENT OF PROBLEM OR QUESTION

Traditional hospital based clerkships and block ambulatory clerkships provide little opportunity to expose students to the type of care typically provided in contemporary primary care practices. Neither, is there time in the traditional curriculum to teach about the less clinically oriented topics which are key to providing efficient, high quality, cost-effective, evidence-based and ethically sound care of patients.

OBJECTIVES OF PROGRAM/INTERVENTION

Some of the objectives of the “Managing Care Curriculum” include understanding: healthcare delivery systems, the evidenced-based approach to practice, ethical dilemmas in practice, the physician's role in community based health assessment, potential barriers to optimal outcomes, as well as improved communication skills and increased exposure to ambulatory primary care practice.

DESCRIPTION OF PROGRAM/INTERVENTION

A six month, year three “Continuity Clinic Clerkship” (CCC) was developed. Students attend “clinic” one half day per week in the offices of volunteer, community based physicians. The CCC was developed and is run by a collaboration of the Departments of Internal Medicine, Family Medicine and Pediatrics with strong support of the Curricular Dean. In addition to caring for many ambulatory patients, including several who are seen multiple times in follow-up visits over the six months, students work on several “Clinical Learning Exercises” (CLEs). In completing the CLEs, students solve problems and consider several questions which are tied to the objectives. There is a written final examnation. A web based pre-test is used in conjunction with the final exam to evaluate the effectiveness of the clerkship.

FINDINGS TO DATE

There is a demonstrable improvement in knowledge of the material relating to the objectives during the clerkship. The CLEs are a vehicle to re-inforce curricular content introduced in years one and two as well as to introduce new material The clerkship has become well institutionalized and widely accepted.

KEY LESSONS LEARNED

This type of clerkship is successful and easily modifiable to allow the curriculum to remain current and relevant. Maintaining a large community based clerkship is challenging but manageable. Interdisciplinary cooperation is key to developing and maintaining large scale curricular change.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

We will display our syllabus, including the CLE's, as well as our evaluation of the effectiveness of the clerkship.

THE AREA OF CONCENTRATION IN UNDERGRADUATE MEDICAL EDUCATION.T. Bui¹; M.A. McNeil¹. ¹University of Pittsburgh, Pittsburgh, PA. (Tracking ID #116159)

STATEMENT OF PROBLEM OR QUESTION

Medical students with particular interest in subjects such as women's health, geriatric medicine, disabilities medicine, and underserved populations find inadequate support and stimulation from traditional medical school curricula.

OBJECTIVES OF PROGRAM/INTERVENTION

The objective of the Area of Concentration (AOC) curricula is to enable medical students to pursue a rigorous, longitudinal academic program of their specific interest in addition to the standard curriculum. Under the guidance of dedicated academic and community mentors and through a structured approach, AOC students acquire the necessary knowledge, attitudes, and skills to work with special needs populations. The School of Medicine recognizes successful completion of the program by granting a Certificate.

DESCRIPTION OF PROGRAM/INTERVENTION

Four Areas of Concentration were formally recognized by the Curriculum Committee in 1999: disabilities medicine, underserved populations, women's health, and geriatric medicine. They share these common requirements—scholarly project, longitudinal experience, reflection, required electives, service-learning, and mentoring. Students are recruited in the first year through a formal application process. Weekly meetings of students and faculty mentors are important in maintaining contacts and interest throughout the four years. Poster presentation and certificate awards are presented to all AOC students who successfully complete all the requirements at the time of graduation.

FINDINGS TO DATE

The AOC in women's health and underserved populations are sponsored by faculty in the division of general internal medicine. Forty seven students have been awarded the AOC certificates in these 2 areas in the past 4 years. A large proportion of the scholarly projects involves surveys, needs assessment and health promotional activities. All the students surveyed believe that the AOC experience has been very rewarding. A majority of students feel that the AOC experience helps them improve their leadership skills and become a more culturally competent health care provider. Although many students plan to work with the AOC population of interest after residency, their career choices are quite diverse and not directly linked to their AOC interest.

KEY LESSONS LEARNED

A longitudinal curriculum for medical students designed to promote sustained interest and scholarship in health care for specific populations is achievable through the support of dedicated faculty mentors. Students acknowledge the significant influence that a longitudinal curriculum has on their commitment to the population of interest and in their personal and professional development.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Examples of student portfolios and poster presentations will be displayed at Meeting.

THE DESIGN AND IMPLEMENTATION OF A NEW MUSCULOSKELETAL MEDICINE ELECTIVE FOR THIRD-YEAR MEDICAL STUDENTS.E. Anish¹; M. Elnicki¹. ¹University of Pittsburgh, Pittsburgh, PA. (Tracking ID #116958)

STATEMENT OF PROBLEM OR QUESTION

Studies suggest that a marked disparity exists between the frequency of musculoskeletal (MSK) problems presenting to general medical practices and the adequacy of training for medical school graduates. A need exists to improve the education that medical students receive in MSK medicine.

OBJECTIVES OF PROGRAM/INTERVENTION

1) To design and implement an elective rotation in MSK medicine. 2) To improve the competency of medical students in the evaluation and management of common MSK disorders.

DESCRIPTION OF PROGRAM/INTERVENTION

A 3-week elective for third-year medical students was created combining the following: 7 half-day clinic sessions [primary care sports medicine (internal medicine/family medicine), orthopedics, rheumatology, and physiatry], 1 half-day of didactics, MSK exam workshops, and case discussions, and 1 half-day for self-directed study (utilizing a teaching syllabus and recommended readings). 1 half-day session was reserved for non-elective-related medical school teaching activities. Students also had the opportunity to help provide medical care at evening and weekend high school athletic events under faculty supervision.

FINDINGS TO DATE

A total of 7 students completed the rotation during the 2002–03 academic year. Their MSK medicine competency was assessed in 3 ways: 1) Score on a multiple-choice (MC) exam administered pre- and post-elective. 2) Score on the MSK questions included in a standardized MC exam given to all third-year students at the end of their required Ambulatory Care Clerkship (ACC). 3) Score on a MSK objective structured clinical examination (OSCE) station included as part of a multi-station OSCE completed at the end of the ACC. All 7 students showed improvement on their post-elective MC exam (12.1 vs. 15.1, P < .01). Compared to their peers, who did not choose the rotation, students completing the MSK medicine elective scored higher on the MSK questions included in the ACC MC exam (3.7 vs. 2.7, P = .01) and on the MSK station included in the ACC OSCE (91 vs. 77, P = .02). On both the ACC MC test and the OSCE, there was no significant difference in overall test scores between the students completing the elective and those who did not (P > 0.5 for both). Verbal and written feedback regarding the elective was extremely positive. The success of this elective is further reflected by having the maximal number of students (14) selecting this rotation for the 2003–04 academic year.

KEY LESSONS LEARNED

A multi-disciplinary MSK medicine elective that utilizes several teaching-modalities can be successfully implemented as part of a medical school curriculum. Students completing this elective demonstrated significant improvement in their knowledge of MSK medicine and in their MSK physical examinations skills.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

THE DRAMA OF ETHICS: “LISTENING TO LIFE”. C. Barnard¹; K. Neely²; J. Hauser². ¹Northwestern Memorial Hospital, Chicago, IL; ²Northwestern University, Chicago, IL. (Tracking ID #115916)

STATEMENT OF PROBLEM OR QUESTION

Finding the time and the appropriate setting to discuss ethical challenges in patient care can be difficult. Theater may offer an innovative framework to overcome these difficulties and allow clinicians to explore ethical challenges and their own personal reactions to their work roles and experiences.

OBJECTIVES OF PROGRAM/INTERVENTION

To use drama to initiate conversations among clinicians of various backgrounds about challenges in medical ethics and patient care. To foster interdisciplinary support among health care teams.

DESCRIPTION OF PROGRAM/INTERVENTION

The Medical Ethics Committee of an medical center sent an open letter soliciting “stories of caregiving” from hospital staff. The Committee's theme for the year was “Strangers at a Bad Time”: the notion that we enter the lives of patients and families—often strangers—at difficult times, yet when intimacy is often most needed. More than forty stories emerged. A professional playwright and director helped craft the stories into a 45 minute play, “Listening to Life” which was cast entirely from hospital staff. While the script wove stories together in a dramatic narrative, it also emphasized the writers' experience of the demands and fulfillments of caregiving. The play was performed seven times for hospital staff and as the invited plenary program for a hospital-wide conference of oncology nurses during 2003. The play was also featured in the Chicago Tribune.

FINDINGS TO DATE

More than 650 people attended “Listening To Life.” Approximately 150 returned formal evaluations, rating the program 4.9 on a 5-point Likert scale for quality and desirability of repeating it. Qualitative feedback was enthusiastic, emotional, and eloquent: “This reminded me of why I became a nurse.”“It's like I was so very empty—and this performance filled me up.”“It seems like so often we hear about the negative things in medicine (lawsuits, economics, etc) but are not reminded of what an enriching and wonderful profession it can be…It made me excited that I will, one day, be able to help people. Even more importantly, much of this helping seems not to have much to do with medicine, but merely compassion.” Videotapes have been shared with six hospitals and programs for their educational use. Consultations to the Medical Ethics Committee have increased from 1–2 to 8–10/month.

KEY LESSONS LEARNED

Caregivers were eager to offer their stories, their energies as cast and crew, and to attend and discuss this performance. With this commitment of time and energy, and modest financial resources, we enriched the Medical Ethics program, made it more accessible, and found this warmly received by our colleagues.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster or oral presentation. Videotape clips of performance also available.

THE EFFECT OF AN AMBULATORY CHIEF RESIDENT AND AN AMBULATORY MORNING REPORT ON INTERNAL MEDICINE RESIDENTS' PERCEPTION OF PRIMARY CARE. S.L. Alt¹; S. Glavin²; X. Zhang²; J.N. Woodruff¹. ¹University of Chicago, Chicago, IL; ²The University of Chicago, Chicago, IL. (Tracking ID #116463)

STATEMENT OF PROBLEM OR QUESTION

Does the installation of an ambulatory chief resident and an ambulatory morning report improve internal medicine residents' perceived fund of knowledge and skills in primary care and their attitudes towards primary care?

OBJECTIVES OF PROGRAM/INTERVENTION

(1) To improve internal medicine residents' fund of knowledge in ambulatory medicine. (2) To improve internal medicine residents' attitudes towards primary care. (3) To improve the functioning of the resident continuity clinics and overall ambulatory rotation.

DESCRIPTION OF PROGRAM/INTERVENTION

PGY2 and PGY3 internal medicine residents participate in month long rotations in ambulatory medicine every 6 months. The rotation includes experiences in urgent care, continuity clinics, outpatient subspecialty clinics and lectures covering outpatient medicine topics and evidence-based medicine. In order to enhance learning opportunities and improve the overall ambulatory experience, half way through the academic year we instituted a new ambulatory chief resident and started an ambulatory morning report three times a week. We surveyed the residents before and after the intervention to assess whether their attitudes towards primary care had changed and to whether their perceived fund of knowledge and skills had improved.

FINDINGS TO DATE

We constructed dichotomous variables indicating the residents' reported improvement in their ability to practice general internal medicine and provide care in their continuity clinics with respect to fund of knowledge, interviewing skills, physical exam, differential diagnosis, test selection and treatment plan. By Chi-squared tests, statistically significant improvement was found in residents' perception of their fund of knowledge of general internal medicine (chi square = 0.03) and in the residents' perception of their ability to provide care in their continuity care clinics with respect to creating differential diagnoses (chi square = 0.04). A notable improvement in the residents' perception of their interviewing skills in their continuity clinic was also demonstrated (chi-square = 0.098).

KEY LESSONS LEARNED

The installation of an ambulatory chief resident and of an ambulatory morning report improved residents' perception of their fund of knowledge and their ability to perform in their continuity clinics, specifically with respect to their differential diagnoses and interviewing skills. The changes in the ambulatory rotation did not change attitudes towards primary care.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

THE EFFECT OF AN INTERACTIVE EVALUATION SKILLS WORKSHOP FOR FACULTY AND RESIDENTS ON THE COMPLETION RATE AND QUALITY OF THIRD YEAR MEDICAL STUDENT EVALUATIONS. D.T. Rubin¹; J.N. Woodruff¹. ¹University of Chicago, Chicago, IL. (Tracking ID #117133)

STATEMENT OF PROBLEM OR QUESTION

Do faculty development workshops in evaluation skills improve completion rate and quality of evaluations performed on third-year medical students during their clerkship experiences?

OBJECTIVES OF PROGRAM/INTERVENTION

1. To improve faculty and resident completion rate of student evaluations. 2. To improve the quantity and quality of information included in the narrative section of student evaluations.

DESCRIPTION OF PROGRAM/INTERVENTION

Residents and attendings from the Department of Obstetrics and Gynecology participated in an interactive evaluation skills module lasting one hour. Participants reviewed the principles of evaluation, reviewed the roles of evaluation in medical education, identified barriers to effective evaluations and created strategies to overcome these barriers. Appropriate use of anchored Leikert rating scales and strategies for formulating effective narrative comments were also reviewed.

FINDINGS TO DATE

Three hundred and sixty-seven consecutive written evaluations performed on 133 students before the intervention and two hundred and sixty consecutive written evaluations performed on 102 students after the intervention were analyzed retrospectively. Analysis of both completion rate and the quality of narrative sections of student evaluations was performed. There was no difference in the completion rate of evaluations performed after the intervention compared to before the intervention. There was also no difference in both the average length of the narratives and documentation of feedback in the narratives after the intervention compared to before the intervention. There was a significant improvement in the number of specific examples of behavior documented in the narrative after the intervention compared to before the intervention. The average number of examples increased by 57% with a P value of .020.

KEY LESSONS LEARNED

Faculty development workshops in evaluation skills have no benefit in improving the completion rate of student evaluations. They may improve the quality of narrative comments by teaching faculty to use more specific examples of student behavior but do not seem to increase amount of narrative or documentation of feedback. The extremely low frequency with which specific examples of behavior and feedback are documented in the narrative suggests evaluators in medical education do a poor job of providing adequate detail in the narrative.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster.

TRAINING GENERAL INTERNISTS FOR INTERNATIONAL HUMANITARIAN ASSISTANCE MISSIONS.J.E. Rinaldo¹; E. Berbano²; K. Dezee². ¹Walter Reed Army Medical Center, Washington, DC; ²Walter Reed Army Medical Center, Bethesda, MD. (Tracking ID #103196)

STATEMENT OF PROBLEM OR QUESTION

The term “general internal medicine” (GIM) implies a global scope. Yet there has been little effort in US GIM training programs to teach medicine appropriate to developing countries where poverty and conflict abound. Our trainees in a US Army medical center sends graduates to such settings frequently. Thus we need to develop training for our IM residents, and we are a natural nidus for exporting it to other GIM programs in the non-military sector. In a globalized medical environment beset by instability and marred by poverty, all internists should possess this knowledge base.

OBJECTIVES OF PROGRAM/INTERVENTION

1. To identify the educational needs of IM physicians who perform humanitarian assistance medicine (HAM) in the US Army. 2. To use extramural didactic and field training in HAM within the GIM fellowship to train HAM “trainers.” 3. To develop a formal curriculum in humanitarian assitance medicine (HAM) for all IM residents within our program. 4. To disseminate our HAM curriculum to other IM training programs in the non-military sector.

DESCRIPTION OF PROGRAM/INTERVENTION

To identify the educational needs of IM physicians who participate in HAM, we have designed an assessment tool for distribution to all Army IM graduates in years 2002–2005 in order to assess their perception of the gaps in their residency in HAM and their level of post-graduate participation in HAM. To train GIM trainers at the fellowship level, we have instituted graduate training in disaster medicine and have planned international non-military humanitarian field experiences through collaboration with a non-governmental organization NGO. We have begun a lecture series for IM residents on HAM. Finally, we have begun planning a national symposium through the Army ACP to publicize and disseminate these innovations.

FINDINGS TO DATE

All graduates and current members of our training program have been polled via electronic communications. These communications have revealed nearly universal interest by current trainees and substantial participation by previous trainees in HAM worldwide. A quantitative assessment tool has been designed for use by training directors of all six Army IM programs. We have identified five broad subject areas: Disaster epidemiology, maternal-child healthcare, tropical medicine, public health priorities for refugees, and the international healthcare relief community. Eight lectures have been given on these subjects. Efforts are underway to monitor the effectiveness of the program by pre and post testing of residents and by sequential administration of the assessment tool after deployment of the current (trained) residency cohorts.

KEY LESSONS LEARNED

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

USE OF COMPUTER SIMULATED LUNG SOUNDS IN AN INTRODUCTORY TO PHYSICAL EXAM COURSE: DO STUDENTS THINK IT WORKS?J. Jevtic¹; J.L. Sebastian¹; D. Bragg¹. ¹Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #115656)

STATEMENT OF PROBLEM OR QUESTION

Successfully teaching the skill of pulmonary auscultation in the classic lecture-discussion(LD) and small group model is associated with multiple barriers including recruitment of patients, changing auscultory findings, and the inability to objectively assess the knowledge and skills attained by student learners.

OBJECTIVES OF PROGRAM/INTERVENTION

To improve the knowledge and skills of second year(M2) students in pulmonary auscultation and assess their ability to accurately identify normal and abnormal lung sounds using PneumoSim^R, a computerized lung sound simulator.

DESCRIPTION OF PROGRAM/INTERVENTION

Following a one hour lecture on pulmonary exam and a small group session with patient interactions, we used the PneumoSim^R to introduce a new case-based curriculum that highlighted abnormal pulmonary auscultory findings associated with six common pulmonary diseases(asthma, pneumonia, pleural effusion, pneumothorax, heart failure and COPD). Immediately after the teaching module all students(n = 174) underwent a 15 question quiz to test their fund of knowledge to accurately identify normal and abnormal lung sounds. M2 students also completed a pre/post self assessment rating their confidence in their ability to identify lung sounds(1 = not confident; 6 = very confident). Paired t-tests were used to examine differences between pre and post student ratings.

FINDINGS TO DATE

Student's mean score on the quiz was 94.5%(8.0) with a range 60–100%. M2 students reported that their ability to identify normal breath sounds, wheezes, crackles, pleural friction rubs and egophony all significantly improved after their exposure to the PneumoSim^R curriculum (P < .001). Despite the fact that only 54% of the students felt that the computer-simulated sounds were easy to hear using the infrared stethoscopes, 72% felt that this portion of the curriculum contributed positively to their ability to accurately identify common lung sounds. Overall, 81% of the students felt that the PneumoSim^R should be used in future teaching sessions.

KEY LESSONS LEARNED

Results of our pretest/posttest self-assessment survey indicated that M2 students felt that their ability to accurately identify lung sounds significantly improved after exposure to the PneumoSim curriculum.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

USE OF PELVIC SIMULATOR FOR RESIDENT PELVIC EXAM SKILLS TRAINING.K.S. Jorn¹. ¹Society of General Internal Medicine, Jacksonville, FL. (Tracking ID #116199)

STATEMENT OF PROBLEM OR QUESTION

Entering G1 residents have varying degrees of skill in performing pelvic examinations. It is technically difficult to arrange live patient examinations for our resident trainees. Alternative methods of teaching and assessing resident pelvic examination skills are needed.

OBJECTIVES OF PROGRAM/INTERVENTION

1) To assess basic resident skills in performing a pelvic examination. 2) To provide a forum for teaching basic pelvic examination skills. 3) To assess whether trainee level of confidence and performance of pelvic examinations were improved by the use of a simulator and a dedicated training session on pelvic examinations.

DESCRIPTION OF PROGRAM/INTERVENTION

New G1 residents were assigned to attend a 1.5 hour “Pelvic Examination Teaching Session” run by the primary author during the first 2 weeks of their first Ambulatory Rotation. Sessions consisted of a brief interactive didactic session followed by trainee examination of two commercially available Pelvic Simulators (NASCO products http://www.enasco.com/prod/Home). Then trainees were taken to an examination room and “walked through” a pelvic exam and Pap smear with demonstration of the equipment, policies, and procedures used at our institution.

FINDINGS TO DATE

Feedback on the sessions has been positive in general. For those residents who already had a good background in pelvic examinations, the simulators did not add much to the benefit of the session overall. Those residents who felt their exam skills were weaker did percieve some benefit from the simulators. Chart review shows little impact of the intervention sessions on pelvic exam performance but an effect would be difficult to capture in our patient population.

KEY LESSONS LEARNED

Pelvic simulators are not substitutions for examination of live patients but can provide an arena for basic skill assessment. Residents with a good foundation in GYN examination skills do not derive much additional benefit from the use of simulators. Residents find the didactic information and introduction to the policies and procedures of our institution helpful regardless of their baseline skill level. In our patient population, quantitative benefit of these sessions are difficult to assess. Similar sessions may be useful in other institutional settings as the difficulty in using live patients for resident education increases.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Poster or Verbal description of the Pelvic Examination Teaching Sessions. NASCO Pelvic Exam Simulator will be available for examination by meeting attendees.

USING AN AUDIENCE RESPONSE SYSTEM TO TEACH ABOUT PHYSICIAN-INDUSTRY INTERACTIONS.M. Stellini¹. ¹Wayne State University, Detroit, MI. (Tracking ID #116597)

STATEMENT OF PROBLEM OR QUESTION

Many physicians-in-training, as well as practicing physicians are likely unaware of guidelines about appropriate physician-industry interactions. Inappropriate interactions between industry representatives and physicians, particularly trainees, can have a negative impact on patient care and healthcare expenditures.

OBJECTIVES OF PROGRAM/INTERVENTION

The objective is to present the American Medical Association (AMA) guidelines on physician-industry interaction as an example of an ethical, professional framework for behavior, to mixed audiences of faculty physicians and trainees. The secondary objective is to stimulate thought and self-reflection on this topic by using an audience response system during didactic sessions.

DESCRIPTION OF PROGRAM/INTERVENTION

A didactic session is delivered, which explains the AMA guidelines and their rationale. The session is made interactive by interspersing questions to the audience within the didactic material and discussing the responses immediately. Audience members respond via individual keypads and the responses are displayed electronically to the group as histograms after polling on each question is completed. Each individual's response remains anonymous; only aggregate data is displayed.

FINDINGS TO DATE

Most trainees and many faculty are unaware of the AMA guidelines or that any such guidelines exist. Many faculty and trainees endorse (and engage in) practices that are outside of the recommendations of the guidelines. Some audience members are willing to change behaviors after these sessons. The audience response system greatly enhances the value of the session by stimulaing discussion by audience members.

KEY LESSONS LEARNED

There is a need to educate practicing/faculty physicians as well as trainees about guidelines for appropriate interaction with industry representatives. Discussing the potential impact of such relations on clinical care and healthcare expenditures is important. Using an audience reponse system, “forcing” participants to declare their position on pertinent questions, enriches and improves the discussion. This type of presentation is a good means to begin a process of attitude and behavior change where appropriate.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

We will display the powerpoint presentation including questions and audience responses. We will discuss some interventions that can be done to change behavior which are enhanced by this presentation.

USING MUSIC TO TEACH BEGINNING HEART SOUNDS.S.E. Hoar¹; H. Straker². ¹George Washington University, Hyattsville, MD; ²George Washington University, Washington, DC. (Tracking ID #115184)

STATEMENT OF PROBLEM OR QUESTION

Beginning heart sounds are typically taught by a combination of lecture and the use of recorded sounds, sometimes with a concommittant sound wave display and/or electrocardiographic recording. Students typically focus on taking notes instead of hearing and assessing the sound and clinically on the use and adjustment of the stethoscope. How can students learn the initial qualities of heart sounds without worrying about the cause or significance of the sound?

OBJECTIVES OF PROGRAM/INTERVENTION

To help students begin to hear and assess heart sounds.

DESCRIPTION OF PROGRAM/INTERVENTION

First year Physician Assistant students were given a 45 minute music session before any lecture on heart sounds or an introduction to use of the stethoscope. A local musician used multiple instruments in a live, interactive session. Students listened to a short piece, then tapped the rhythm and answered questions. The music session was followed by a short description of use of the stethoscope. The students then listened to their own heart sounds. Finally, the students received standard lectures with the use of prerecorded heart sounds.

FINDINGS TO DATE

Students were able to identify regular and irregular, slow, medium, and fast rhythms, pauses, gallops, split sounds, murmurs, and a rub.

KEY LESSONS LEARNED

Students enjoyed the break from the lecture format and focused on hearing the sounds and rhythms. The evaluation showed that the majority felt prepared to hear real heart sounds and that the program should be continued.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Either live music and/or CD will be demonstrated, if accepted for oral presentation.

“WORLDS APART”: USING DOCUMENTARY FILMS TO TEACH CROSS-CULTURAL HEALTH CARE.A.R. Green¹; J.R. Betancourt²; M. Grainger-Monsen³. ¹Beth Israel Deaconess Medical Center, Boston, MA; ²Massachusetts General Hospital, Boston, MA; ³Stanford University, Palo Alto, CA. (Tracking ID #116972)

STATEMENT OF PROBLEM OR QUESTION

Cross-cultural education is now recognized as a necessary component in medical training at all levels. Innovative methods and tools are needed to engage students in this important area of learning.

OBJECTIVES OF PROGRAM/INTERVENTION

Documentary film is a particularly powerful medium for allowing its audience to connect with real people's experiences, and for fostering empathy and awareness. In order to bring to life the actual conflicts, issues and challenges faced by patients and healthcare professionals in cross-cultural medical encounters, we helped develop a series of short documentary films for use as teaching tools. We also developed a facilitator's guide to help educators lead meaningful, reflective discussions about these issues. The specific objectives are for learners to: 1) understand that patients and clinicians often have different values, beliefs, and perspectives on health and illness that can lead to conflict; 2) become familiar with challenges that are particularly relevant in cross-cultural healthcare; 3) develop a greater sense of curiosity, empathy, and respect towards patients who are culturally different.

DESCRIPTION OF PROGRAM/INTERVENTION

The program consists of four short films (10 to 14 minutes in length) that tell the stories of four patients, their families, and the healthcare professionals who care for them. These stories raise issues of patient mistrust, communication barriers due to language and culture, racial/ethnic disparities and stereotyping, and traditional alternative practices, among others. They deal with medical situations such as dialysis and renal transplantation, repair of an atrial-septal defect, gastric cancer, and the management of chronic medical illness. The films can be used in a variety of settings including large group presentations with reflective break-out sessions, as adjuncts for problem-based learning, and in courses on cross-cultural medicine, physician and patient, ethics, or social and behavioral sciences.

FINDINGS TO DATE

Two of the films were piloted with 150 first-year Harvard medical students followed by break-out sessions. The response was positive overall with average session ratings of 4.4 (4 = very good, 5 = excellent).

KEY LESSONS LEARNED

The Worlds Apart documentary films and facilitator's guide represent an innovative approach to raising the awareness of physicians-in-training to the relevance of cross-cultural issues in health care. They can be feasibly implemented into undergraduate and graduate medical curricula in a variety of ways. Further studies are needed to assess the impact of these films on cross-cultural knowledge and attitudes.

MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING

Video, poster and printed materials