Sustaining the development of primary care in academic medicine. Working Group on Sustaining the Development of Academic Primary Care. Association of American Medical Colleges

Developing Medical Students' Broad Clinical Diagnostic Reasoning Through GP-Facilitated Teaching in Hospital Placements

PURPOSE

Graduating medical students need broad clinical diagnostic reasoning skills that integrate learning across clinical specialties to deal with undifferentiated patient problems. The opportunity to acquire these skills may be limited during clinical placements on increasingly specialized hospital wards. We developed an intervention of regular general practitioner (GP) facilitated teaching in hospital placements to enable students to develop broad clinical diagnostic reasoning. The intervention was piloted, refined and delivered to a whole cohort of medical students at the start of their third year. This paper examines whether students perceived opportunities to improve their broad diagnostic clinical reasoning through our intervention.

METHODS

GP-facilitated teaching sessions were delivered weekly in hospital placements to small groups of 6-8 students for 90 mins over 6 weeks. Students practiced clinical reasoning with real patient cases that they encountered on their placements. Evaluation of learning outcomes was conducted through a student questionnaire using Likert scales with free-text boxes for additional explanation. Focus groups were conducted to gain a more in-depth understanding of student perspectives.

RESULTS

As high as 87% of students agreed that their broad clinical diagnostic reasoning ability had improved. Thematic analysis of the qualitative data revealed four factors supporting this improvement: practicing the hypothetico-deductive method, using real patient cases, composing student groups from different speciality placements and the breadth of the facilitators' knowledge. Students additionally reported enhanced person-centredness in terms of understanding the patient's perspective and journey. Students perceived that the added value of general practitioner facilitators lay in their broad knowledge base and knowledge of patient needs in the community.

CONCLUSION

Our results suggest that medical students can develop broad clinical diagnostic reasoning skills in hospital settings through regular GP-facilitated teaching. Our approach has the advantage of working within the established curricular format of hospital placements and being deliverable at scale to whole student cohorts.

Preparing anesthesiology faculty for competency-based medical education

PURPOSE

Competency-based medical education (CBME) is quickly becoming the dominant organizing principle for medical residency programs. As CBME requires changes in the way medical education is delivered, faculty will need to acquire new skills in teaching and assessment in order to navigate the transition. In this paper, we examine the evidence supporting best practices in faculty development, propose strategies for faculty development for CBME-based residency programs, and discuss the results of faculty development initiatives at the pioneering anesthesia CBME residency program at the University of Ottawa.

SOURCE

Review of the current literature and information from the University of Ottawa anesthesia residency program.

PRINCIPAL FINDINGS

Faculty development is critical to the success of CBME programs. Attention must be paid to the competence of faculty to teach and assess all of the CanMEDS roles. At the University of Ottawa, some faculty development initiatives were very successful, while others were hindered by factors both internal and external to the residency program. Many faculty development activities had low attendance rates.

CONCLUSIONS

Faculty development must be considered in the rollout of any new educational initiative. Experts suggest that faculty development for CBME should incorporate educational activities using multiple teaching and delivery methods, and should be offered longitudinally through the planning, development, and implementation phases of curriculum change. Additionally, these educational activities must continue until all faculty have demonstrated an acceptable level of competence. Faculty buy-in is paramount to the successful delivery of any faculty development program that is not mandatory in nature.

Do primary health centres and hospitals contribute equally towards achievement of the transversal clinical competencies of medical students? Performance on the Objective Structured Clinical Examination (OSCE) in competency acquisition

Objectives

The adaptation of the educational programmes of European faculties of medicine to the European Higher Education Area guidelines has focused curricula design on competence acquisition. Competencies are defined as the achievements of a predetermined level of efficacy in real-world scenarios. Our objective was to assess whether performance on a common competence evaluation test, the Objective Structured Clinical Examination (OSCE), resulted in different scores for second-year students after a practical medical training course took place in a primary health centre (PHC) or in a hospital.

Design

A descriptive study was conducted during the 2010–2014 academic year of the OSCE test scores obtained by all second-year students.

Location

Faculty of Medicine at the University of Lleida (Catalonia, Spain).

Main measurements

We performed a correlation analysis between students who completed their practical medical training at the PHC and hospitals utilising Student's t-test for comparison of means.

Results

423 students who completed internships at the PHC and at hospitals obtained OSCE mean scores of 7.32 (SD; IC) (0.82; 7.18–7.47) points and 7.17 (0.83; 6.07–7.26) points, respectively (p = 0.07).

Conclusions

Second-year medical students acquired similar competency levels in the two analysed training scenarios. The two areas both serve their teaching purpose.

Patients' attitudes towards medical students in a teaching family practice: a sri lankan experience

Background:

Faculty of Medicine, University of Kelaniya, Sri Lanka conducts a one month under graduate training programme during their fourth year at the University family practice centre. Students get training in history taking, clinical examination, patient management and practice management during this attachment. This study was conducted to look at the patients’ attitude towards student participation during consultation.

Materials and Methods:

This was a descriptive cross sectional study. All the patients who were 16 years and above during a 2 month period were included in the study. Structured questionnaire was administered by demonstrators following a consultation where students were present. Their demographic data, number of consultations with student participation and questions related to presence of students at various stages of the consultation were asked.

Results:

Total of 85 patients took part in the study and 81.3% of them were females. 88.8% were of the opinion that they benefited by the interaction with medical students while 93.8% thought students understood their problems. 26.3% patients preferred a medical student of the same sex during consultation while 71.3 had not expressed any opinion in this regard. Only 3.8% and 5% wanted the doctor alone during history taking and examination respectively. Almost every patient was happy that they could help the undergraduate training.

Discussion:

As expected results of the study showed that patients were willing to take part in undergraduate training without any reservation. These results are compatible with the previous studies done in the western world and data is not available form either Sri Lanka or other Asian countries.

A 'minimal core curriculum' for Family Medicine in undergraduate medical education: a European Delphi survey among EURACT representatives

BACKGROUND

Family Medicine/General Practice (FM/GP) has not developed in a similar way worldwide. In countries that are not primary care oriented, the discipline of FM/GP may be less developed because this is not a career option for medical graduates. In such a situation, FM/GP will not be regarded as a required clinical experience during medical school.

OBJECTIVES

To define the 'minimal requirements' or 'minimal core content' for a clerkship in FM/GP of very short duration, i.e. a basic curriculum for a clinical rotation in FM/GP, taking into account that in some European countries the time allocated for this rotation may not exceed one week.

METHOD

The Delphi method was used. The study group was composed of 40 family physicians and medical educators who act as national representatives of all European countries-plus Israel-in the Council of the European Academy of Teachers in General Practice and Family Medicine (EURACT). The representatives are elected among the EURACT members in their country.

RESULTS

After three Delphi rounds we obtained a consensual list of 15 themes regarded by the respondents as the most important to be included in a minimal core curriculum for FM/GP in undergraduate medical education.

CONCLUSION

This list may be useful for teachers and institutions that are about to introduce GP/FM as a new topic in their medical faculty, having only limited time available for the course. They will be able to focus on topics chosen by a European expert panel as being the most important in such a situation.

The importance of faculty development in the transition to competency-based medical education

Medical teachers trained in conventional educational systems need faculty development to prepare them to function effectively in a competency-based medical education (CBME) system. Faculty development can provide knowledge about CBME, training in new teaching techniques in different domains of medical practice, and new strategies for providing the authentic and regular assessment that is an essential aspect of CBME. A systems-wide approach as well as efforts to provide training in CBME to individual teachers in both the undergraduate and postgraduate systems will be important. The wide implementation of CBME will be challenging and slow, and will meet with resistance, but various strategies can be used address these challenges. Faculty development is fundamental to the effectiveness of those strategies.

Building an interprofessional curriculum framework for health: a paradigm for health function

There is an increasing call for curricula in health care to facilitate interprofessional client-centred evidence-based decision making through a reflective and reflexive framework. This discussion paper proposes that adoption of the World Health Organisation, International Classification of Functioning, Disability and Health (ICF) as a framework for curricula of health professionals promotes the necessary paradigm shift needed to legitimise a broad evidence base as the foundation of interprofessional dialogue. Client function is seen as the product of an open system incorporating the individual, social and environmental influences on behaviour, with the role of the professional being to acknowledge the context of individual behaviour through an understanding of individual's functioning in their environment. It is concluded that client focused practice and an iterative process of clinical reasoning based on a broad evidence base that conceptualises health care as the maintenance and promotion of health across the lifespan requires a re-conceptualising of health. The emerging concept shifts the primary emphasis of health care away from post-diagnosis tertiary care towards clients who maintain a life-long independence in the community.

The views of U.S. medical school deans toward academic primary care

PURPOSE

To understand the views of U.S. medical school deans about their primary care faculties.

METHOD

In 2000, the authors mailed a questionnaire containing 43 multipart items to deans of 130 U.S. allopathic medical schools. The questionnaire assessed the deans' attitudes about and evaluation of primary care at their school and their school's efforts to strengthen it. Deans were asked to compare family medicine, general internal medicine, and general pediatrics with nonprimary care clinical departments at their schools.

RESULTS

Of the 83 (64%) deans who responded, 82% reported their school had departments or divisions of family medicine, general internal medicine, and general pediatrics. Deans rated general internal medicine and general pediatrics higher than nonprimary care faculty on clinical expertise and productivity (p < .001) and family medicine equivalent to nonprimary care faculty. Deans rated all three primary care faculties superior to nonprimary care faculty for teaching skills (p < .001) and programs (p < .05), but lower than nonprimary care disciplines for research productivity (p < .01) and revenues (p < .001). They rated family medicine and general pediatrics lower for research skills (p < .001), but 73% of deans stated research was equally important for primary care and nonprimary care departments. Deans considered overall financial resources to be equivalent for primary care and nonprimary care departments, but 77% of deans felt primary care departments or divisions needed financial support from the medical school to survive. Most deans attempted to strengthen primary care by changing the curriculum to promote primary care and by providing financial support.

CONCLUSIONS

Deans ranked primary care faculty high on clinical and teaching measures. Although they considered research to be an important activity for primary care faculty, they evaluated it low relative to nonprimary care departments.

Teaching the teachers: national survey of faculty development in departments of medicine of U.S. teaching hospitals

OBJECTIVE

To determine the prevalence, topics, methods, and intensity of ongoing faculty development (FD) in teaching skills.

DESIGN

Mailed survey.

PARTICIPANTS

Two hundred and seventy-seven of the 386 (72%) U.S. teaching hospitals with internal medicine residency programs.

MEASUREMENTS

Prevalence and characteristics of ongoing FD.

RESULTS

One hundred and eight teaching hospitals (39%) reported ongoing FD. Hospitals with a primary medical school affiliation (university hospitals) were more likely to have ongoing FD than non-university hospitals. For non-university hospitals, funding from the Health Resources Services Administration and >50 house staff were associated with ongoing FD. For university hospitals, >100 department of medicine faculty was associated. Ongoing programs included a mean of 10.4 topics (standard deviation, 5.4). Most offered half-day workshops (80%), but 22% offered > or =1-month programs. Evaluations were predominantly limited to postcourse evaluations forms. Only 14% of the hospitals with ongoing FD (5% of all hospitals) had "advanced" programs, defined as offering > or =10 topics, lasting >2 days, and using > or =3 experiential teaching methods. These were significantly more likely to be university hospitals and to offer salary support and/or protected time to their FD instructors. Generalists and hospital-based faculty were more likely to receive training than subspecialist and community-based faculty. Factors facilitating participation in FD activities were supervisor attitudes, FD expertise, and institutional culture.

CONCLUSIONS

A minority of U.S. teaching hospitals offer ongoing faculty development in teaching skills. Continued progress will likely require increased institutional commitment, improved evaluations, and adequate resources, particularly FD instructors and funding.

Marketplace reforms and primary care career decisions

A dramatic shift in the postgraduate career choices of medical school graduates toward primary care occurred during the mid-1990s. While some attributed this shift to changes in medical school curricula, perceptions stemming from marketplace reforms were probably responsible. For the most part, these perceptions were probably generated through informal communications among medical students and through the media. More recently, additional marketplace influences, such as the consumer backlash toward managed care and unrealized gains in primary care physicians' personal incomes, may have fostered contrasting perceptions among medical students, leading to career choices away from primary care, particularly family practice. The authors offer two recommendations for enhancing the knowledge of medical students concerning workforce supply and career opportunities: an educational seminar in the second or third year of medical school, and a public-private partnership between the Bureau of Health Professions and the Association of American Medical Colleges to create a national database about the shape of the primary care and specialty workforces, accessible through the Internet for educators, students, and policymakers. The authors conclude that appropriate career counseling through these efficient methods could avoid future abrupt swings in specialty choices of medical school graduates and may facilitate a more predictable physician workforce supply.

Measuring emotional intelligence of medical school applicants

PURPOSE

To discuss the development, pilot testing, and analysis of a 34-item semantic differential instrument for measuring medical school applicants' emotional intelligence (the EI instrument).

METHOD

The authors analyzed data from the admission interviews of 147 1997 applicants to a six-year BS/MD program that is composed of three consortium universities. They compared the applicants' scores on traditional admission criteria (e.g., GPA and traditional interview assessments) with their scores on the EI instrument (which comprised five dimensions of emotional intelligence), breaking the data out by consortium university (each of which has its own educational ethos) and gender. They assessed the EI instrument's reliability and validity for assessing noncognitive personal and interpersonal qualities of medical school applicants.

RESULTS

The five dimensions of emotional intelligence (maturity, compassion, morality, sociability, and calm disposition) indicated fair to excellent internal consistency: reliability coefficients were .66 to .95. Emotional intelligence as measured by the instrument was related to both being female and matriculating at the consortium university that has an educational ethos that values the social sciences and humanities.

CONCLUSION

Based on this pilot study, the 34-item EI instrument demonstrates the ability to measure attributes that indicate desirable personal and interpersonal skills in medical school applicants.

When should learning about hospitalized patients end? Providing housestaff with post-discharge follow-up information

PURPOSE

As hospital stays grow shorter, many patients are discharged to follow up with their primary care physicians before their diagnoses and responses to treatment are clear. The authors studied the value and feasibility of providing housestaff with follow-up information about their former inpatients.

METHOD

Patients included in the study (1) had been admitted to the housestaff service during the study period (January to March 1997), (2) had received follow-up care from a primary care physician in the Johns Hopkins Bayview Physicians' Professional Association, and (3) had been hospitalized for at least three days. The primary care physician completed a single-page follow-up form four to six weeks after the patient's discharge from the hospital; that form was given to the house officers who had cared for that patient.

RESULTS

Responses to a preintervention questionnaire completed by 28 of 39 house officers (72%) showed that 92% felt it to be important or extremely important to get follow-up information about inpatients; 86% indicated that they rarely or never receive such information. During the study period, house officers were sent follow-up information for 65 of 76 eligible patients (85%). In their responses to a post-intervention questionnaire (response rate 73%), the house officers most valued learning about the accuracy of the discharge diagnosis, the results of additional diagnostic tests, and information about the patient's quality of life since discharge. Housestaff's satisfaction with the follow-up information received about inpatients improved (p = .001).

CONCLUSIONS

Providing follow-up information was a feasible intervention that was valued by housestaff.

Influence on general practitioners of teaching undergraduates: qualitative study of London general practitioner teachers

OBJECTIVE

To examine the perceived effect of teaching clinical skills and associated teacher training programmes on general practitioners' morale and clinical practice.

DESIGN

Qualitative semistructured interview study.

SETTING

General practices throughout north London.

SUBJECTS

30 general practitioners who taught clinical skills were asked about the effect of teaching and teacher training on their morale, confidence in clinical and teaching skills, and clinical practice.

RESULTS

The main theme was a positive effect on morale. Within teacher training this was attributed to developing peer and professional support; improved teaching skills; and revision of clinical knowledge and skills. Within teaching this was attributed to a broadening of horizons; contact with enthusiastic students; increased time with patients; improved clinical practice; improved teaching skills; and an improved image of the practice. Problems with teaching were due to external factors such as lack of time and space and anxieties about adequacy of clinical cover while teaching.

CONCLUSION

Teaching clinical skills can have a positive effect on the morale of general practitioner teachers as a result of contact with students and peers, as long as logistic and funding issues are adequately dealt with.