Showing papers in "Academic Medicine in 1994"

The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education.

Abstract: The authors raise questions regarding the wide-spread calls emanating from lay and medical audiences alike to intensify the formal teaching of ethics within the medical school curriculum. In particular, they challenge a prevailing belief within the culture of medicine that while it may be possible to teach information about ethics (e.g., skills in recognizing the presence of common ethical problems, skills in ethical reasoning, or improved understanding of the language and concepts of ethics), course material or even an entire curriculum can in no way decisively influence a student's personality or ensure ethical conduct. To this end, several issues are explored, including whether medical ethics is best framed as a body of knowledge and skills or as part of one's professional identity. The authors argue that most of the critical determinants of physician identity operate not within the formal curriculum but in a more subtle, less officially recognized "hidden curriculum." The overall process of medical education is presented as a form of moral training of which formal instruction in ethics constitutes only one small piece. Finally, the authors maintain that any attempt to develop a comprehensive ethics curriculum must acknowledge the broader cultural milieu within which that curriculum must function. In conclusion, they offer recommendations on how an ethics curriculum might be more fruitfully structured to become a seamless part of the training process.

Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development

Abstract: BACKGROUND. Little is known about the ethical dilemmas that medical students believe they encounter while working in hospitals or how students feel these dilemmas affect them. The authors examine how clinical students perceive their ethical environment, their feelings about their dilemmas, and wheth

What clinical teachers in medicine need to know.

Abstract: In order to identify the components of knowledge that effective clinical teachers of medicine need, the author carried out a qualitative study of six distinguished clinical teachers in general internal medicine in 1991. Using data from interviews, a structured task, and observations of each ward team, he identified six domains of knowledge essential to teaching excellence in the context of teaching rounds: clinical knowledge of medicine, patients, and the context of practice, as well as educational knowledge of learners, general principles of teaching and case-based teaching scripts. When combined, these domains of knowledge allow attending physicians to engage in clinical instructional reasoning and to target their teaching to the specific needs of their learners. The results of this investigation are discussed in relation to both prior research on teacher knowledge, reasoning, and action and faculty development in medicine.

Stress, coping, and well-being among third-year medical students.

Abstract: BACKGROUND Medical school is recognized as a stressful environment that often exerts a negative effect on the academic performance, physical health, and psychological well-being of the student METHOD Stress, coping, depression, and somatic distress were examined among 69 third-year students compl

Elaborated knowledge: a key to successful diagnostic thinking.

Abstract: No abstract available.

The influence of the New Pathway curriculum on Harvard medical students.

Abstract: BACKGROUND. This study evaluated the effect of a radically redesigned curriculum at Harvard Medical School on preclinical students' knowledge, skills, personal characteristics, approaches to learning, and educational experiences. METHOD. Multiple measures were used to collect data from 121 students

Historical background of clinical trials involving women and minorities

Abstract: The author provides a historical context for the difficult ethical and clinical issues associated with the inclusion of women and members of minority groups in clinical research. He cites as a point of departure the Nuremberg Code of the late 1940s, which declared the fundamental dignity of human beings involved as research subjects, a principle that was quickly endorsed worldwide. From the period following World War II through the 1970s, the prevailing attitude--not always practiced--toward research subjects in the United States was that they should be protected from exploitation. That attitude was reflected in the first broad federal policy on research subjects, created in 1966. During those years, research was widely regarded by the public as dangerous and of little value to individual participants; it is remarkable that so many men and women consented to participate in clinical studies at that time. Furthermore, during the 1970s, for reasons explained by the author, various events--the abortion debate, disclosures from the infamous Tuskegee syphilis study, Nixon's "war on cancer," new federal regulations in 1974 and 1975 (the latter providing additional protection for pregnant women in research), the broad interpretation of the FDA's 1977 policy excluding pregnant or potentially pregnant women from clinical trials, and the tendency of blacks and persons from other minority groups to shun participation in research--tended to deter participation of women and members of minority groups in clinical research.(ABSTRACT TRUNCATED AT 250 WORDS)

The Americans with Disabilities Act: I. History, summary, and key components.

Abstract: This report presents (1) a brief history and summary of the Americans with Disabilities Act and (2) an extensive section of definitions and explanations of key components--such as disability, qualified individual with a disability, reasonable accommodation, and undue hardship--and their relevance to medical schools. While these definitions are numerous and somewhat technical, an understanding of them is essential for medical school faculty, staff, and administrators to assess the Act's impact on and implications for their institutions and to assure adequate and appropriate compliance. Gaining such understanding is important, for although some authorities believe that the Act will have minimal impact on most colleges and universities, the author maintains that experience at her medical school does not support this view. A companion article, published in this issue of Academic Medicine, focuses on the implications of the Act for colleges of medicine and offers suggestions for compliance.

Three exemplary models of case-based teaching.

Abstract: Teaching in response to case presentations is an essential feature of clinical teaching in medicine. Yet, this form of case-based teaching is often done poorly. Using qualitative methods of interviews, observations, and recordings of teaching rounds, the author describes three different yet exemplary pedagogical strategies for organizing teaching rounds in general internal medicine. These include: (1) case-bedside teaching that involves case discussion in a conference room followed by demonstrations at the bedside, (2) case-lecture teaching that blends quick reviews of cases with more formal presentations on relevant topics, and (3) case-iterative teaching that involves discovery-learning using complex cases. From these three case studies, five general principles of experiential learning in clinical settings are derived: anchoring instruction in cases, actively involving learners, modeling professional thinking and action, providing direction and feedback, and creating a collaborative learning environment. These three approaches to teaching rounds overcome common problems associated with learning in clinical settings.

Effect of Online Literature Searching on Length of Stay and Patient Care Costs.

Abstract: PURPOSE. To examine the associations between (1) the economic indicators of hospital costs, charges, and length of stay (LOS) for inpatient cases and (2) the use of MEDLINE searches for such cases. METHOD. An outcome-based, objective, prospective study with an economic evaluation was conducted from

The research we should be doing.

Abstract: No abstract available.

Resolving inconsistencies in tutor expertise research: does lack of structure cause students to seek tutor guidance?

Abstract: Purpose. To investigate under what conditions tutors' subject-matter expertise influences student achievement. Method. Data were analyzed from 1,800 University of Limburg Faculty of Health Sciences students who in 1989- 90 participated in tutorial groups led by content-expert staff tutors, non- expert staff tutors, or student tutors. Each student participated in an average of 4.1 tutorial groups. Overall, 4,111 data records were available for analysis. The basic analyses were of (1) students' achievement scores as a function of tutors' levels of subject-matter expertise and students' prior knowledge; (2) students' achievement scores as a function of tutors' levels of subject-matter expertise and educational units' levels of structure; and (3) differences in achievement between students guided by tutors of different levels of expertise in either high- or low-structure units. Statistical methods included analyses of variance. Results. The level of subject-matter expertise of tutors had a positive influence on student achievement. Similar results were found for the students' prior knowledge and the levels of structure of the units; the more prior knowledge students had the better were their performances on the end-of-unit test; and the higher the level of structure of the unit, the better the achievement. More important, interactions were found between tutor expertise on the one hand and prior knowledge and unit structure on the other, tutor expertise being mainly important if the unit was poorly structured or students reported lack of prior knowledge. Conclusion. The results suggest that students need a minimum level of structure in order to profit from problem-based instruction. This structure can be internally provided through prior knowledge available for understanding the new subjects, or offered by the environment in the form of cues of what is relevant and what should be the focus of the activities. If prior knowledge falls short, or if the environment lacks structure, students will turn to their tutors for help and direction. Under those conditions, students who are guided by a subject-matter expert tutor may benefit more than students guided by a non-expert staff tutor or by a student tutor. These findings may explain the widely divergent results of tutor-expertise research.

Factors influencing the specialty choices of 1993 medical school graduates.

Abstract: The authors describe how the 8,128 medical school seniors who completed the 1993 AAMC Medical School Graduation Questionnaire (GQ) rated the influence that each of 36 factors (such as interest in helping people) had on their specialty decisions, using a 0 to 4 Likert-type scale where 4 indicated a major influence on specialty choice. The list of factors and their mean ratings are presented to show those of greatest influence (e.g., type of patient problems encountered, rated 3.44), of moderate influence (e.g., type of patients encountered; 2.75), and of limited influence (e.g., length of residency; 1.18). Factors' ratings also are compared across specialty groups. While the seven most influential factors were given about the same weight by the seniors regardless of their specialty choice, there were significant differences in the ratings of other factors across specialties (e.g., patient contact factors were rated higher by future generalists than by graduates favoring other specialties). The GQ respondents' ratings of factors over time are compared for 1991, 1992, and 1993. Last, those respondents who had changed their minds about a specialty were asked to rate the 36 factors according to how strongly they had influenced the rejection of the previous specialty choice; most of the factors were rated as having been of minor influence. As a general rule, income prospects and educational debt were not strong influences, either on specialty choice or rejection. The authors state that the influences of the factors they have reported are those that set the initial direction of graduates' residency training.(ABSTRACT TRUNCATED AT 250 WORDS)

An alternative approach to defining the role of the clinical teacher.

Abstract: BACKGROUND. A number of studies have attempted to identify the components of the clinical teacher role by examining learners' numerical ratings of items on researcher-generated lists. Some of these studies have also compared different groups' perceptions of clinical teaching, but have not directly c

Resident-patient interactions: The humanistic qualities of internal medicine residents assessed by patients, attending physicians, program supervisors, and nurses

Abstract: BACKGROUND. The patient-physician relationship is central to medical practice. Increasingly, educators and certifying bodies seek to assess trainees' humanistic qualities. METHOD. The humanistic qualities of first-year internal medicine residents were rated in 1987–88 and 1988–89 by patients hospita

A comparative analysis of the costs of administration of an OSCE (objective structured clinical examination).

Abstract: Background The objective structured clinical examination (OSCE) has become an accepted technique for the evaluation of clinical competence in medicine. Although advances have been made in our knowledge of the psychometric aspects of the OSCE, extremely little has been written about feasibility and cost issues. Given the current economic imperative to control costs and the extremely scant literature on the costs of developing and administering an examination in medicine, the authors felt it timely and relevant to explore issues related to the cost of the OSCE. Method In 1991-92 and in 1992-93, costs and time requirements to implement and administer a structured oral (SO) examination and a six-station OSCE for a surgical clerkship at the University of Toronto Faculty of Medicine were gathered by review of invoices, interviews with those involved, and perusal of diaries kept by staff. Results To develop and administer the six-station OSCE, 327.5 hours of staff and faculty time were required for each rotation of surgical clerks (8.2 hours per student). The SO examination required 110 hours of staff and faculty time (2.75 hours per student). Direct expenses for the OSCE amounted to U.S. $6.90 per student per station, compared with no direct expense for the SO examination. Conclusion The OSCE was more time-consuming and more expensive in human and material costs than the SO examination. However, costs of the OSCE can be substantially reduced from approximately U.S. $35 to U.S. ! per student per station if test developers, standardized patients, support staff, and examiners can donate their time. The authors compare the costs and time requirements of their OSCE with those of other OSCEs reported in the literature, and they provide guidelines to assist educators in deciding whether the costs of an OSCE are justifiable in the educators' individual settings.

Cheating by students: findings, reflections, and remedies

Abstract: Cheating among students is surprisingly frequent and may be increasing. The 1991 study reported herein was prompted by an episode of cheating involving three second-year medical students at the University of New Mexico School of Medicine (UNM SOM) and was undertaken (1) to elicit the opinions of faculty members and students at that institution about whether selected descriptions of students' behaviors were unethical; (2) to document possible discrepancies between the opinions of the two groups concerning these behaviors; (3) to define the prevalence of unethical behavior among current students as estimated by faculty and students; and (4) to determine how best to approach future instances of unethical behavior. Questionnaires were distributed to all faculty and students. The first two parts, sent to both groups, concerned reactions to a series of described physician and student behaviors. For each described behavior, respondents were asked whether or not it was unethical and, for the described student behaviors, whether they had personal knowledge of such behavior by local medical students. The third portion of the questionnaire concerned faculty perceptions regarding students' behaviors over time. With the exception of the class involved in the cheating incident, faculty and students were surprisingly similar in their opinions regarding the ethical nature of the described behaviors. According to both faculty and students, there was a significant incidence ( > or = to 10% of the respondents) of unethical behavior at the school of medicine, most commonly in relation to cheating on examinations.(ABSTRACT TRUNCATED AT 250 WORDS)

Learning, experience, and self-assessment of competence of third-year medical students in performing bedside procedures

Abstract: BACKGROUND. Third-year medical students are expected to perform common bedside procedures as part of their daily ward activities, but there are few programs to teach these skills or document students' abilities to perform them. PURPOSE. In addition to describing the clinical procedures course at the

Faculty and administration views of problems in faculty evaluation.

Abstract: PURPOSE To identify problems in how medical school faculty are evaluated, from the perspectives of faculty and administrators, and to understand how perceptions of the problems differ among those with varying roles within the medical school. METHOD In March 1992 seven copies of an open-ended questionnaire were sent to each dean at the 126 accredited U.S. medical schools and 16 affiliated Canadian schools. The deans were instructed to complete one form themselves and to distribute one copy each to (1) a faculty affairs dean, (2) a basic science chair, (3) a clinical chair, (4) a member of chair of the school's promotion and tenure committee, (5) a senior faculty member, and (6) a junior faculty member. The authors conducted a content analysis of narrative comments in response to a question that began "Please identify and briefly describe the most salient problems you observe at your institution in how faculty are evaluated." RESULTS Of a possible 994 responses, 455 (46%) were received. The respondents were from 102 of the 126 U.S. medical schools (81%) and eight of the 16 Canadian schools (50%). Response rates for the respondent subgroups ranged from 27% for the deans to 57% for the clinical chairs. Overall, the most frequently mentioned problems concerned the evaluation of teaching. General complaints about the inadequacy of current methods to evaluate teaching performance were most common--more than one in four respondents raised this issue--but the respondents also had specific complaints about student evaluations of teaching and the insufficient recognition given to teaching in the academic reward system. The frequencies with which other concerns were expressed tended to be related to the respondents' roles. These problems included concerns about the methods and measures used to assess research and scholarship and the quality of clinical care, the nonuniformity of evaluation processes and criteria for promotion among departments, the absence of regular evaluations, and the failure to link the results of evaluation to salary. CONCLUSION The study population was not random; indeed, it was probably biased toward those who felt strongly (and perhaps negatively) about the current evaluation system. Still, the intensity with which views were expressed was striking. Improving the evaluation of faculty teaching undoubtedly remains one of medical education's greatest challenges.

Cultural-sensitivity training in U.S. medical schools

Abstract: BACKGROUND. As the United States becomes more multicultural, physicians face the challenge of providing culturally sensitive and appropriate health care to patients with differing health beliefs and values. While a few schools are providing cultural-sensitivity training in response to the changing p

Medical education about substance abuse: changes in curriculum and faculty between 1976 and 1992.

Abstract: PURPOSE: To examine changes in substance abuse education in U.S. medical schools between 1976 and 1992. METHODS. In 1991–92 the authors conducted a 16-year follow-up survey of six clinical departments in each of the 126 U.S. medical schools. Two previous surveys by scholars and surveys conducted by the Liaison Committee on Medical Education, Association of American Medical Colleges, and the National Center for Medical Fellowships in the Addictions provided baseline data for comparison. The statistical methods used in the comparisons were paired t-tests, one-way analyses of variance, and tests of differences between proportions. RESULTS. Significant increases were found in the numbers of required and elective curriculum units for medical students between 1986–87 and 1991–92. The number of medical schools requiring courses in substance abuse treatment increased from five to eight between 1986–87 and 1991–92. For residents, there were significant increases in the numbers of curriculum units for residents in family medicine and pediatrics. The average number of faculty in the 116 medical schools that reported units on substance abuse was 4.1. There were 45 fellowships in addiction medicine identified in 1991–92, with a total of 61 fellows in training. CONCLUSION. While the findings confirm positive changes, the amount of curricula time and the number of faculty having expertise in substance abuse education do not compare well with the amounts of time and numbers of faculty involved in clinical problems of similar prevalence, such as cancer and heart disease.

Faculty development through formal mentoring.

Abstract: No abstract available.

Effect of processing strategy on diagnostic skill in dermatology.

Abstract: No abstract available.

Practice-based small-group CME.

Abstract: No abstract available.

Educating medical students: lessons from research in continuing education.

Abstract: Creating a true continuum of medical education from admission to medical school throughout a lifetime of professional learning is easier said than done. To do so, the various components on the continuum must be explored to determine where appropriate links might be made. The author considers selected concepts and evidence from the theory and practice underlying continuing medical education (CME) and continuing professional education (CPE) insofar as CME and CPE can inform undergraduate medical curricula, including its current innovations. Five conceptual and empirical approaches from CME and CPE are discussed in detail: social learning theory, how physicians learn and change, competence in business and the professions, how professionals learn in practice, and lifelong self-directed learning. Then the author describes the implications of these approaches for the ongoing development of undergraduate medical education. (1) The entire learning environment, and not merely discrete aspects such as curriculum content, must be examined and fully utilized to benefit learning. (2) The importance of the contexts in which learning occurs must be emphasized in several ways. (3) Learning should be centered around clinical problems. (4) The many benefits of small-group learning and other ways of learning from colleagues should be emphasized. (5) The undergraduate curriculum should emphasize the development of students' feelings of self-efficacy to ensure that students become physicians who are confident about their abilities. (6) CME research and CPE research reinforce the efforts in undergraduate medical education to emphasize the early development of students' process skills as well as content mastery.

Social responsibility and the academic medical center: building community-based systems for the nation's health.

Abstract: Academic medical centers have fulfilled several of their missions with immense success but have failed to fulfill others. They have responded only modestly to the needs of the nation's underserved rural and urban communities. The author calls on academic medical centers to take an aggressively active role in building the medical infrastructure now missing in these communities and outlines a multi-part agenda for institutional commitment. It includes developing community-based systems of primary care, outreach programs, and social supports; training professionals committed to serving isolated and poor communities; and performing research that will extend the knowledge base to include the health and social issues of the disadvantaged. (Examples are given of institutions that have pioneered these kinds of community-based activities.) To build the new infrastructure, financing must be secured (various sources are discussed), a community-based faculty must be developed, and each institution's leadership--the medical school dean, the hospital executive, and the department chairmen--must come together around a new agenda and support it materially and psychologically, making whatever changes are needed in the corporate culture. The author warns that if centers do not undertake this responsibility for the health of the underserved, a critical job will go undone, a huge opportunity will have been missed, and American society will be the poorer.

The effect of teaching medical students on private practitioners' workloads.

Abstract: BACKGROUND. The costs in time and money of medical student education for family physicians in private practice is uncertain, with the literature containing conflicting reports. METHOD. Questionnaires were mailed in 1992–93 to 56 primary care physicians who had taught third- or fourth-year students during the previous academic year in fulfillment of the students' required four-week family medicine preceptorships at the University of Missouri-Columbia School of Medicine. RESULTS. Forty-six physicians responded. The physicians had been preceptors for 74 students. Most of the physicians reported increases in time spent at work (mean of 46 minutes per day, standard deviation of 32 minutes) when a student was present in their practices. Only five noted decreases in billed charges. CONCLUSION. The preceptors were consistent in their indications that having students in their offices increased their time at work. This suggests that teaching medical students places a substantial temporal burden on private practitioners.

The effect of a class in medical ethics on first-year medical students.

Abstract: PURPOSE To assess the effect of a class in medical ethics on first-year medical students. METHOD A test instrument was developed to measure the attitudes of medical students toward certain ethical questions and to assess their factual knowledge regarding particular legal and ethical issues. The instrument was administered in 1992-93 to 110 first-year students at the University of Virginia School of Medicine before and after the students took a required course in medical ethics. The instrument employed clinical vignettes as well as multiple-choice, true-false, and Likert-scale questions. Its reliability and validity were assessed. RESULTS The required course in medical ethics had little influence on the students. There was only one significant change (p = .05) in the pattern of responses to any of the clinical vignettes. In a few of the attitude-oriented queries, there were statistically significant changes (p < .05) after the course. Although there were statistically significant changes for only four of the factual-knowledge questions, for all such questions more students identified the correct answers after the class (before the course the range of correct answers was 43% to 99% compared with 64% to 100% after the course). CONCLUSION The class in medical ethics seemed to have little effect on the first-year students, probably because students arrive at medical school with well-established ethical perspectives.

Evaluation of clinical teaching by general internal medicine faculty in outpatient and inpatient settings

Abstract: PURPOSE: To determine the measurement characteristics of a form used to evaluate teaching in outpatient settings, and to compare ratings received by general internists in outpatient and inpatient settings. METHOD: The physicians evaluated were 29 faculty who taught in both outpatient and inpatient settings affiliated with the Department of Medicine, University of Washington School of Medicine, over a five-year period (from 1985-86 through 1989-90). Residents completed 639 evaluations, using a six-point Likert-type scale (from 1, very poor, to 6, excellent) to rate instructors in eight categories and to provide an overall assessment of each instructor's teaching effectiveness. In addition, each evaluation contained an indication of the resident's perceived degree of involvement with the instructor. Statistical analysis involved two-tailed t-tests, analysis of variance and covariance, intraclass correlation coefficients, and the Spearman Brown prophecy formula. RESULTS: When more than ten raters of teaching in outpatient settings were available, the reliabilities ranged from .58 to .81. The outpatient-setting ratings were significantly lower than the inpatient-setting ratings for seven categories, overall teaching effectiveness (5.01 versus 5.35, p < .05), and perceived degree of involvement of the instructor with the resident. When controlled for perceived degree of involvement, differences remained in only two categories: demonstration of clinical skills, rated higher for outpatient settings, and instructor accessibility, rated lower. CONCLUSION: The evaluation form provides reliable ratings of teaching in outpatient settings when more than ten raters are available. The differences found in the ratings between the inpatient and outpatient settings may be explained by the factor of the resident's perceived degree of involvement with the instructor.

Physician incompetence: specific problems and predictors.

Abstract: No abstract available.