Impact of a clinical preventive medicine curriculum for primary care faculty: results of a dissemination model

A train-the-trainer approach to a shared pharmacogenomics curriculum for US colleges and schools of pharmacy

OBJECTIVE

To assess pharmacy faculty trainers' perceptions of a Web-based train-the-trainer program for PharmGenEd, a shared pharmacogenomics curriculum for health professional students and licensed clinicians.

METHODS

Pharmacy faculty trainers (n=58, representing 39 colleges and schools of pharmacy in the United States and 1 school from Canada) participated in a train-the-trainer program consisting of up to 9 pharmacogenomics topics. Posttraining survey instruments assessed faculty trainers' perceptions toward the training program and the likelihood of their adopting the educational materials as part of their institution's curriculum.

RESULTS

Fifty-five percent of faculty trainers reported no prior formal training in pharmacogenomics. There was a significant increase (p<0.001) in self-reported ability to teach pharmacogenomics to pharmacy students after participants viewed the webinar and obtained educational materials. Nearly two-thirds (64%) indicated at least a "good" likelihood of adopting PharmGenEd materials at their institution during the upcoming academic year. More than two-thirds of respondents indicated interest in using PharmGenEd materials to train licensed health professionals, and 95% indicated that they would recommend the program to other pharmacy faculty members.

CONCLUSION

As a result of participating in the train-the-trainer program in pharmacogenomics, faculty member participants gained confidence in teaching pharmacogenomics to their students, and the majority of participants indicated a high likelihood of adopting the program at their institution. A Web-based train-the-trainer model appears to be a feasible strategy for training pharmacy faculty in pharmacogenomics.

Medicare part D community outreach train-the-trainer program for pharmacy faculty

OBJECTIVES

To assess the train-the-trainer component of an initiative (Partners in D) to train pharmacy students to facilitate patient enrollment in the best Medicare Part D prescription drug plan (Part D).

METHODS

Faculty members from 6 California colleges or schools of pharmacy were taught how to train pharmacy students about Medicare Part D and how to conduct outreach events targeting underserved patient populations. A preintervention and postintervention survey instrument was administered to determine participants' (1) knowledge of the Part D program; (2) skill using the Medicare Prescription Drug Plan Finder tool; and (3) confidence in their ability to train pharmacy students. Implementation of the Partners in D curriculum in faculty members' colleges or schools of pharmacy was also determined.

RESULTS

Participants' knowledge of Part D, mastery of the Plan Finder, and confidence in teaching the material to pharmacy students all significantly improved. Within 8 weeks following the program, 5 of 6 colleges or schools of pharmacy adopted Partners in D coursework and initiated teaching the Partners-in-D curriculum. Four months afterwards, 21 outreach events reaching 186 Medicare beneficiaries had been completed.

CONCLUSIONS

The train-the-trainer component of the Partners in D program is practical and effective, and merits serious consideration as a national model for educating patients about Medicare Part D.

Evaluation of a train-the-trainer program for tobacco cessation

OBJECTIVES

To assess pharmacy faculty members' perceptions of the Rx for Change tobacco cessation program materials and train-the-trainer program.

METHODS

Pharmacy faculty members attended a 14.5 hour train-the-trainer program conducted over 3 days. Posttraining survey instruments assessed participants' (n = 188) characteristics and factors hypothesized to be associated with program adoption.

RESULTS

Prior to the training, 49.5% of the faculty members had received no formal training for treating tobacco use and dependence, and 46.3% had never taught students how to treat tobacco use and dependence. Participants' self-rated abilities to teach tobacco cessation increased posttraining (p < 0.001). The curriculum materials were viewed as either moderately (43.9%) or highly (54.0%) compatible for integration into existing curricula, and 68.3% reported they were "highly likely" to implement the program in the upcoming year.

CONCLUSIONS

Participation in a national train-the-trainer program significantly increased faculty members' perceived ability to teach tobacco-related content to pharmacy students, and the majority of participants indicated a high likelihood of adopting the Rx for Change program at their school. The train-the-trainer model appears to be a viable and promising strategy for promoting adoption of curricular innovations on a national scale.

Evaluation of a train-the-trainer program for cultural competence

OBJECTIVES

To develop, implement, and evaluate the impact of a cultural competence train-the-trainer workshop for pharmacy educators.

METHODS

A 2-day train-the-trainer workshop entitled Incorporating Cultural Competency in Pharmacy Education (1.65 CEUs) was provided to pharmacy faculty from schools across the United States. Baseline, posttraining, and 9-month follow-up surveys assessed participants' (n = 50) characteristics and self-efficacy in developing and teaching content.

RESULTS

At baseline, 94% of faculty members reported no formal training in teaching cultural competence. After completing the workshop, participants' self-rated confidence for developing and teaching workshop content significantly increased. The number of participants who rated their ability to teach cultural competence as "very good" or "excellent" increased from 13% to 60% posttraining. Participants reported teaching 1 or more aspects of the workshop curriculum to nearly 3,000 students in the 9-months following training.

CONCLUSIONS

The workshop significantly increased faculty members' perceived and documented ability to teach cultural competence. The train-the-trainer model appears to be a viable and promising strategy for meeting the American Council for Pharmacy Education accreditation standards relating to the teaching of diversity, cultural issues, and health literacy.

Diffusion and dissemination of evidence-based dietary strategies for the prevention of cancer

OBJECTIVE

The purpose was to determine what strategies have been evaluated to disseminate cancer control interventions that promote the uptake of adult healthy diet?

METHODS

A systematic review was conducted. Studies were identified by searching MEDLINE, PREMEDLINE, Cancer LIT, EMBASE/Excerpta Medica, PsycINFO, CINAHL, the Cochrane Database of Systematic Reviews, and reference lists and by contacting technical experts. English-language primary studies were selected if they evaluated the dissemination of healthy diet interventions in individuals, healthcare providers, or institutions. Studies of children or adolescents only were excluded.

RESULTS

One hundred one articles were retrieved for full text screening. Nine reports of seven distinct studies were included; four were randomized trials, one was a cohort design and three were descriptive studies. Six studies were rated as methodologically weak, and one was rated as moderate. Studies were not meta-analyzed because of heterogeneity, low methodological quality, and incomplete data reporting. No beneficial dissemination strategies were found except one that looks promising, the use of peer educators in the worksite, which led to a short-term increase in fruit and vegetable intake.

CONCLUSIONS AND IMPLICATIONS

Overall, the quality of the evidence is not strong and is primarily descriptive rather than evaluative. No clear conclusions can be drawn from these data. Controlled studies are needed to evaluate dissemination strategies, and to compare dissemination and diffusion strategies with different messages and different target audiences.

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

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

A Systematic Review of Studies Evaluating Diffusion and Dissemination of Selected Cancer Control Interventions

With this review, the authors sought to determine what strategies have been evaluated (including the outcomes assessed) to disseminate cancer control interventions that promote the uptake of behavior change. Five topic areas along the cancer care continuum (smoking cessation, healthy diet, mammography, cervical cancer screening, and control of cancer pain) were selected to be representative. A systematic review was conducted of primary studies evaluating dissemination of a cancer control intervention. Thirty-one studies were identified that evaluated dissemination strategies in the 5 topic areas. No strong evidence currently exists to recommend any one dissemination strategy as effective in promoting the uptake of cancer control interventions. The authors conclude that there is a strong need for more research into dissemination of cancer control interventions. Future research should consider methodological issues such as the most appropriate study design and outcomes to be evaluated.

The development and implementation of a curriculum to improve clinicians' self-directed learning skills: a pilot project

BACKGROUND

Clinicians need self-directed learning skills to maintain competency. The objective of this study was to develop and implement a curriculum to teach physicians self-directed learning skills during inpatient ward rotations.

METHODS

Residents and attendings from an internal medicine residency were assigned to intervention or control groups; intervention physicians completed self-directed learning curricular exercises.

RESULTS

Among the 43 intervention physicians, 21 (49%) completed pre- and post-curriculum tests; and 10 (23%) completed the one-year test. Immediately after exposure to the curriculum, the proportion of physicians defining short- and long-term learning goals increased [short-term: 1/21 (5%) to 11/21 (52%), p = 0.001; long-term: 2/21 (10%) to 15/21 (71%), p = 0.001]. There were no significant changes post-curriculum in the quantity or quality of clinical question asking. The physicians' mean self-efficacy (on a 100-point scale) improved for their abilities to develop a plan to keep up with the medical literature (59 vs. 72, p = 0.04). The effects of the curriculum on self-reported learning behaviors was maintained from the immediate post-curriculum test to the one-year post curriculum test: [short-term learning goals: 1/21 (5%) pre-, 11/21 (52%) immediately post-, and 5/10 (50%) one-year after the curriculum (p = 0.0075 for the pre- vs one-year comparison); long-term learning goals: 2/21 (10%) pre-, 15/21 (71%) immediately post-, and 7/10 (70%) one-year (p = 0.0013 for the pre- vs one-year comparison). At one-year, half of the participants reported changed learning behaviors.

CONCLUSIONS

A four-week curriculum may improve self-directed learning skills.

Evaluation of a faculty development program in managing care

PURPOSE

To evaluate a faculty development program that teaches quality improvement and cost-effectiveness.

METHOD

From October 2000 to February 2001, a two-part faculty development program was offered to 39 physicians from 19 U.S. medical schools supported by grants from the Partnerships for Quality Education (PQE) and Undergraduate Medical Education in the 21st Century (UME-21). Special features of the program included partnerships between academic and community physicians from each school, development of an educational innovation of interest to the participants, concurrent development of teaching skills and new medical knowledge, learning leadership skills (e.g., how to train colleagues to teach), and practice periods. The program focused on quality improvement and cost-effectiveness, but included other "managing care" topics. Prior to and after the course, participants assessed their knowledge of and competence to teach these topics, as well as other managing care topics. They also assessed their competence as medical educators and leaders. After the course, they indicated their progress in implementing their proposed educational innovations.

RESULTS

Thirty-two of the 39 physicians completed evaluations both before and after the program. Self-assessed knowledge and competence to teach quality improvement and cost-effectiveness were significantly higher at the end of the course, as were all self-assessed teaching and leadership skills. The largest change scores occurred in assessments of competency to teach the new topics and to teach in new ways. Participants who implemented their innovations rated their competencies to teach quality improvement and cost-effectiveness higher than did non-implementers.

CONCLUSION

Opportunities for faculty to learn how to teach a topic of stated importance to them, to practice what they have learned, and to work collaboratively with partners improved teaching skills.

Effect of clinical teaching on student performance during a medicine clerkship

PURPOSE

To measure what proportion of student clerkship performance can be attributed to teachers' educational skills as reported by students.

SUBJECTS AND METHODS

From August 1992 to June 1994, we collected critiques of teacher skills from 314 third-year students at the end of a 12-week medicine clerkship. Interns, residents, attending physicians, and student preceptors were rated (on a 1 to 5 scale) on teaching behaviors from the 7 categories of the Stanford Faculty Development Program framework. A linear regression model was used to determine the relative contributions of the rated teaching behaviors in predicting final student performance and improvement across the clerkship ("student growth"), measured using end-of-clerkship variables (clinical grades, National Board of Medical Examiners medicine shelf examination, practical laboratory examination, and an analytical essay examination) and preclerkship variables (pre-third-year grade point average [GPA], United States Medical Licensing Examination, Step I, and clerkship pretest).

RESULTS

Data were available for 293 (93%) of 314 students, who completed a total of 2,817 critiques. The students' preclerkship GPA accounted for the greatest percentage of variance in student performance (28%, P < 0.0001). Clinical teaching behaviors accounted for an additional 6% (P < 0.0001) of the variance. For student growth across the clerkship, teaching accounted for 10% of the variance (P < 0.0001). Among the 7 Stanford educational categories, teaching behaviors promoting control of session (r2 = 5%, P = 0.0002) and fostering understanding and retention (r2 = 4%, P = 0.001) had the greatest effect. The resident had the most effect on student growth (r2 = 6%, P = 0.0001) when compared with other teaching levels. Teaching had a greater effect on growth for students with preclerkship GPA above the mean (16% versus 6%), for older students (24% versus 7%), and for students with a nonscience undergraduate degree (33% versus 9%).

CONCLUSION

The preclerkship GPA, reflecting 2 years of work, was the most important predictor of student performance. Teaching behavior, as measured by student assessments, also affected student performance.

Utility of a brief self-efficacy scale in clinical training program evaluation

Self-efficacy is often studied as a predictor of professional practice behaviors or as an outcome of clinical training, using brief scales with little validation. This study examines the utility of a brief self-efficacy scale in the evaluation of a clinical training program. Subjects were 119 registered dietitians who participated in diabetes training. Hypothesized relationships between self-efficacy ratings and indices of skill mastery, participation in training, and subsequent practice change were examined. Self-efficacy ratings after training correlated significantly with relevant prior experience (r = .4 and .29, p < .01) but not total experience and with knowledge post-test score (r = .21, p < .02). Self-efficacy for all 12 program objectives increased significantly after training. Post-training self-efficacy for two program objectives correlated significantly with self-reported successful practice changes related to those objectives (r = .4, p < .04 and r = .51, p < .01). The data suggest that brief self-efficacy assessments can contribute meaningfully to clinical training program evaluation.

Incorporating physical activity advice into primary care: physician-delivered advice within the activity counseling trial

INTRODUCTION

The Activity Counseling Trial (ACT) was designed to compare the effectiveness of physician advice alone with physician advice plus behavioral counseling, provided by ACT-trained health educators, to increase levels of physical activity in healthy, sedentary patients. The objective was to determine health care providers' adherence to the ACT protocol for delivering initial "physician" advice on physical activity and to determine providers' satisfaction with the protocol.

METHODS

Fifty-four physicians or physician assistants from 11 primary care practices located in California, Texas, and Tennessee volunteered to participate as ACT-trained physicians. Providers were trained to integrate 3 to 4 minutes of initial physical activity advice into the routine office visits of sedentary patients, aged 35 to 75 years, with no acute or serious chronic conditions. This advice included assessment of current physical activities, advising the patient about an appropriate physical activity goal, and referring the patient to the health educator. Providers initialed forms to document delivery of advice, and ACT health educators recorded their advice on a computerized tracking system. A provider survey measured length of time spent advising patients about physical activity and provider satisfaction with the program.

RESULTS

Ninety-nine percent of patients received the initial physician advice about physical activity. Eighty-three percent of the providers spent less than 5 to 6 minutes, and 46% spent the recommended 3 to 4 minutes providing advice. Sixty-three percent said the advice resulted in little or no increase in the length of an office visit, and 83% said participation was an asset to their clinics.

CONCLUSIONS

Providers incorporated brief physical activity advice into routine primary care visits with little disruption. Their response to the ACT advice protocol was positive and participation in the study was viewed as beneficial.

Overview of the Activity Counseling Trial (ACT) intervention for promoting physical activity in primary health care settings. Activity Counseling Trial Research Group

Counseling by health care providers has the potential to increase physical activity in sedentary patients, yet few studies have tested interventions for physical activity counseling delivered in health care settings. The Activity Counseling Trial (ACT) is a 5-yr randomized clinical trial to evaluate the efficacy of two primary care, practice-based physical activity behavioral interventions relative to a standard care control condition. A total of 874 sedentary men and women, 35-75 yr of age, have been recruited from primary care physician offices at three clinical centers for 2 yr of participation. They were randomly assigned to one of three experimental conditions that vary, in a hierarchical fashion, by level of counseling intensity and resource requirements. The interventions, which are based on social cognitive theory and the transtheoretical model, are designed to alter empirically based psychosocial mediators that are known to be associated with physical activity. The present paper describes the theoretical background of the intervention, the intervention methods, and intervention training and quality control procedures.