Competency-based learning

Little is known about assessing or improving competency in Papanicolau (Pap) smear sampling among internal medicine residents. We hypothesized that a 3-part targeted resident physician educational program (educational presentation by a knowledgeable instructor, skills workshop, and peer comparison feedback) would be effective in increasing the quality of Pap smears obtained by internal medicine residents. We conducted a randomized, pre-post comparison study over a 16-month period to assess the effect of our educational intervention. We found no difference in baseline adequacy rates. Residents who received the intervention were twice as likely to obtain an adequate Pap smear. Our results suggest that a brief multifaceted intervention designed to improve the frequency with which internal medicine residents obtain endocervical cells while performing Pap smears is effective. This project was funded in part by a pilot grant from the Wake Forest University Center for Health Care Research and Quality. We would like to acknowledge Rebecca Hensberry, MS, for help in data analysis and Stephanie Garrison for data collection and maintenance.     

Impact of a veterans affairs continuity clinic on resident competencies in women’s health

BACKGROUND: Education in women's health is now considered a core curricular component during residency training in Internal Medicine. There is potential for insufficient training in women's health for residents with a continuity clinic based at a Veterans Affairs (VA) hospital. OBJECTIVE: To determine the impact of a 3-year continuity clinic based at a VA hospital on residents' self-reported competencies in women's health. DESIGN: Cross sectional survey using an internal website. SETTING: University-based residency program in Ann Arbor, Michigan. MEASUREMENTS AND MAIN RESULTS: Comparison of residents with a VA clinic with residents with non-VA clinics (university and community) in self-reported competencies in knowledge base, counseling, and physical exam skills in the area of women's health. Responses were obtained from 66% (n = 72) of eligible residents. When compared to residents with either a university hospital- or community-based clinic site, VA-based residents reported less confidence in the majority of competencies surveyed. Clinic site had the strongest impact in the knowledge base domain, accounting for between 17% and 33% of the variance in each specific competency. For estimated number of Pap smears and breast exams done in the prior year, VA-based residents reported doing, on average, less than 5 of each per year while non-VA residents reported doing between 11 and 20 of each exam. CONCLUSIONS: Our data suggest that despite other clinical opportunities in women's health during ambulatory rotations, regular clinical experiences in women's health in the continuity clinic setting are necessary to improve education in this area.     

Tracking Reflective Practice-Based Learning by Medical Students during an Ambulatory Clerkship

Objective To explore the use of web and palm digital assistant (PDA)-based patient logs to facilitate reflective learning in an ambulatory medicine clerkship. Design Thematic analysis of convenience sample of three successive rotations of medical students’ patient log entries. Setting Johns Hopkins University School of Medicine. Participants MS3 and MS4 students rotating through a required block ambulatory medicine clerkship. Interventions Students are required to enter patient encounters into a web-based log system during the clerkship. Patient-linked entries included an open text field entitled, “Learning Need.” Students were encouraged to use this field to enter goals for future study or teaching points related to the encounter. Measurement and Main Results The logs of 59 students were examined. These students entered 3,051 patient encounters, and 51 students entered 1,347 learning need entries (44.1% of encounters). The use of the “Learning Need” field was not correlated with MS year, gender or end-of-clerkship knowledge test performance. There were strong correlations between the use of diagnostic thinking comments and observations of therapeutic relationships (Pearson’s r=.42, p<0.001), and between diagnostic thinking and primary interpretation skills (Pearson’s r=.60, p<0.001), but not between diagnostic thinking and factual knowledge (Pearson’s r =.10, p=.46). CONCLUSIONS We found that when clerkship students were cued to reflect on each patient encounter with the electronic log system, student entries grouped into categories that suggested different levels of reflective thinking. Future efforts should explore the use of such entries to encourage and track habits of reflective practice in the clinical curriculum.     

Web-based curriculum

OBJECTIVE: To address the need for women's health education by designing, implementing, and evaluating a self-study, web-based women's health curriculum. DESIGN: Cohort of students enrolled in the ambulatory portion of the medicine clerkship with comparison group of students who had not yet completed this rotation. PARTICIPANTS/SETTING: Third- and fourth-year medical students on the required medicine clerkship (115 students completed the curriculum; 158 completed patient-related logs). INTERVENTION: Following an extensive needs assessment and formulation of competencies and objectives, we developed a web-based women's health curriculum completed during the ambulatory portion of the medicine clerkship. The modules were case based and included web links, references, and immediate feedback on posttesting. We discuss technical issues with implementation and maintenance. MEASUREMENTS AND MAIN RESULTS: We evaluated this curriculum using anonymous questionnaires, open-ended narrative comments, online multiple-choice tests, and personal digital assistant (PDA) logs of patient-related discussions of women's health. Students completing the curriculum valued learning women's health, preferred this self-directed learning over lecture, scored highly on knowledge tests, and were involved in more and higher-level discussions of women's health with faculty (P<.001). CONCLUSIONS: We present a model for the systematic design of a web-based women's health curriculum as part of a medicine clerkship. The web-based instruction resolved barriers associated with limited curriculum time and faculty availability, provided an accessible and standard curriculum, and met the needs of adult learners (with their motivation to learn topics they value and apply this knowledge in their daily work). We hypothesize that our web-based curriculum spurred students to later discuss these topics with faculty. Web-based learning may be particularly suited for women's health because of its multidisciplinary nature and need for vertical integration throughout medical school curricula.     

Looking back,moving forward: A practical guide to implementing the updated ACGME geriatric medicine Milestones 2.0

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones as a tool to aid trainee assessment based on the framework of the six core competencies of practice. Variability in the interpretation and application of the original Milestones prompted the ACGME to convene work groups within the different specialties and subspecialties to update the Milestones. The Geriatric Medicine work group was convened in 2019 with the goal of clarifying and simplifying the language of the Milestones, revising content to be specific to geriatrics, and developing supplemental resources to aid in implementation and use. We suggest using a practical, four-step process to implement the updated Milestones, called the Milestones 2.0, in fellowship programs by: (1) training faculty in the use of the Milestones 2.0, including an overview of the background and updates, (2) mapping the Milestones 2.0 to existing assessments, (3) educating fellows about the Milestones 2.0 and (4) presenting and discussing the Milestones 2.0 at Clinical Competency Committee meetings. This systematic approach promotes the development of a shared mental model for trainee assessments.     

Osteoporosis risk assessment and ethnicity

BACKGROUND: Dual energy x-ray absorptiometry (DXA), coupled with early treatment, may reduce morbidity and mortality associated with osteoporosis. Clinical tools to enhance selection of women for DXA screening have not been developed or validated in an ethnically diverse population. OBJECTIVE: To compare the performance of the osteoporosis risk assessment instrument (ORAI) and the simple calculated osteoporosis risk estimation (SCORE) instrument across 3 racial/ethnic groups to identify women who would benefit from DXA scans. DESIGN: Blinded comparison of the instruments in a cross-sectional sample. PARTICIPANTS: Two-hundred twenty-six postmenopausal women were recruited from a university-based family medicine clinic. Women with a prior diagnosis of osteoporosis or those taking bone active medications were excluded. MEASUREMENTS: Participants completed a questionnaire that contained the ORAI and the SCORE questions; 203 completed a DXA scan. RESULTS: The sensitivity and specificity for the ORAI (0.68, [0.49 to 0.88, 95% CI]; 0.66, [0.59 to 0.73, 95% CI]) and the SCORE instrument (0.54, [0.34 to 0.75, 95% CI]; 0.72, [0.65 to 0.78, 95% CI]) differed significantly from previous reports. Overall, the accuracy of the ORAI (66.5%) and SCORE instrument (70.0%) were similar (McNemar's test P value = .37). The accuracy between instruments differed significantly in African-American women (McNemar's test, P value <.001). In African Americans, the SCORE instrument correctly identified more women without osteoporosis, but missed 70% of those with osteoporosis. CONCLUSIONS: The performance of the ORAI and SCORE instrument differed significantly from previous reports. Although both can reduce the use of DXA scans for screening for osteoporosis, lower sensitivities resulted in underrecognition of osteoporosis and may limit their clinical usefulness in an ethnically diverse population.     

Evaluating and enhancing a women’s health curriculum in an internal medicine residency program

OBJECTIVE: Resident education in women's health is required but is often underemphasized. Our aim was to identify women's health topics with the most relevance to our graduates' practices and to determine how well they were prepared to address women's health issues. DESIGN: Postgraduate survey. SETTING: University-affiliated internal medicine residency program. PARTICIPANTS: Program graduates in general internal medicine practice. METHODS: A survey was drafted listing the 65 topics described in a published residency curriculum in women's health. Respondents indicated the extent to which each item was relevant to their practice and the adequacy of instruction received on a Likert-type scale of 1 (not relevant/inadequate) to 5 (highly relevant/adequate). RESULTS: The response rate was 86%. Many of the items were highly relevant to our graduates' practices. Learning needs were found in all areas as none of the topics were rated as "adequately" taught during residency. Many areas in the curriculum had low relevance scores. Few differences were seen in the perceived relevance of women's health problems or the adequacy of instruction received based on gender, practice type and setting, or amount of ambulatory training during residency. CONCLUSIONS: Use of this survey has allowed us to tailor and prioritize learning issues in women's health to meet the needs of our graduates. Increased time in ambulatory rotations alone may not be sufficient to prepare residents to provide comprehensive care in this field. Further study of the effectiveness of a dedicated curriculum in women's heath is needed.     

“Oh! she doesn’t speak english!” assessing resident competence in managing linguistic and cultural barriers

BACKGROUND: Residents must master complex skills to care for culturally and linguistically diverse patients. METHODS: As part of an annual 10-station, standardized patient (SP) examination, medical residents interacted with a 50-year-old reserved, Bengali-speaking woman (SP) with a positive fecal occult blood accompanied by her bilingual brother (standardized interpreter (SI)). While the resident addressed the need for a colonoscopy, the SI did not translate word for word unless directed to, questioned medical terms, and was reluctant to tell the SP frightening information. The SP/SI, faculty observers, and the resident assessed the performance. RESULTS: Seventy-six residents participated. Mean faculty ratings (9-point scale) were as follows: overall 6.0, communication 6.0, knowledge 6.3. Mean SP/SI ratings (3.1, range 1.9 to 3.9) correlated with faculty ratings (overall r=.719, communication r=.639, knowledge r=.457, all P<.01). Internal reliability as measured by Cronbach's alpha coefficients for the 20 item instrument was 0.91. Poor performance on this station was associated with poor performance on other stations. Eighty-nine percent of residents stated that the educational value was moderate to high. CONCLUSION: We reliably assessed residents communication skills conducting a common clinical task across a significant language barrier. This medical education innovation provides the first steps to measuring interpreter facilitated skills in residency training.     

Self-Confidence in and Perceived Utility of the Physical Examination: A Comparison of Medical Students,Residents, and Faculty Internists

BACKGROUND AND OBJECTIVES Little is known about the differences in attitudes of medical students, Internal Medicine residents, and faculty Internists toward the physical examination. We sought to investigate these groups’ self-confidence in and perceived utility of physical examination skills. DESIGN AND PARTICIPANTS Cross-sectional survey of third- and fourth-year medical students, Internal Medicine residents, and faculty Internists at an academic teaching hospital. MEASUREMENTS Using a 5-point Likert-type scale, respondents indicated their self-confidence in overall physical examination skill, as well as their ability to perform 14 individual skills, and how useful they felt the overall physical examination, and each skill, to be for yielding clinically important information. RESULTS The response rate was 80% (302/376). The skills with overall mean self-confidence ratings less than “neutral” were interpreting a diastolic murmur (2.9), detecting a thyroid nodule (2.8), and the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature (2.5). No skills had a mean utility rating less than neutral. The skills with the greatest numerical differences between mean self-confidence and perceived utility were distinguishing between a mole and melanoma (1.5), detecting a thyroid nodule (1.4), and interpreting a diastolic murmur (1.3). Regarding overall self-confidence, third-year students’ ratings (3.3) were similar to those of first-year residents (3.4; p = .95) but less than those of fourth-year students (3.8; p = .002), upper-level residents (3.7; p = .01), and faculty Internists (3.9; p < .001). CONCLUSIONS Self-confidence in the physical exam does not necessarily increase at each stage of training. The differences found between self-confidence and perceived utility for a number of skills suggest important areas for educational interventions.     

Teaching medical students about communicating with patients with major mental illness

Persons with major mental illness often have chronic diseases and poor physical health. Therefore, all practicing physicians should learn about communicating effectively with these patients. Few efforts to teach medical students communication skills have specifically targeted patients with major mental illness. Indeed, most of the limited literature on this topic is decades old, predating significant scientific advances in cognitive neuroscience and psychiatric therapeutics and changes in social policies regarding major mental illness. To gather preliminary insight into training needs, we interviewed 13 final-year students from 2 Boston medical schools. Students' observations coalesced around 4 themes: fears and anxieties about interacting with persons with major mental illness; residents "protecting" students from patients with major mental illness; lack of clinical maturity; and barriers to learning during psychiatry rotations. Educational researchers must explore ways to better prepare young physicians to communicate effectively with patients with major mental illness.     

The Portal of Geriatrics Online Education: A 21st‐Century Resource for Teaching Geriatrics

The way students are taught and evaluated is changing, with greater emphasis on flexible, individualized, learner‐centered education, including the use of technology. The goal of assessment is also shifting from what students know to how they perform in practice settings. Developing educational materials for teaching in these ways is time‐consuming and can be expensive. The Portal of Geriatrics Online Education (POGOe) was developed to aid educators in meeting these needs and become quicker, better‐prepared teachers of geriatrics. POGOe contains more than 950 geriatrics educational materials that faculty at 45% of allopathic and 7% of osteopathic U.S. medical schools and the Centers for Geriatric Nursing Excellence have created. These materials include various instructional and assessment methodologies, including virtual and standardized patients, games, tutorials, case‐based teaching, self‐directed learning, and traditional lectures. Materials with common goals and resource types are available as selected educational series. Learner assessments comprise approximately 10% of the educational materials. POGOe also includes libraries of videos, images, and questions extracted from its educational materials to encourage educators to repurpose content components to create new resources and to align their teaching better with their learners' needs. Web‐Geriatric Education Modules, a peer‐reviewed online modular curriculum for medical students, is a prime example of this repurposing. The existence of a robust compendium of instructional and assessment materials allows educators to concentrate more on improving learner performance in practice and not simply on knowledge acquisition. It also makes it easier for nongeriatricians to teach the care of older adults in their respective disciplines.     

Effect of a physical examination teaching program on the behavior of medical residents

CONTEXT: The reliance on physical examination as a diagnostic aid is in decline. OBJECTIVE: To determine whether an educational program can increase the use of physical examination by medical residents. DESIGN AND PARTICIPANTS: A series of educational workshops were provided to 47 second- and third-year medical residents at a large academic teaching hospital. MEASUREMENTS: Interns and students reported the frequency and depth of clinical examination performance on morning rounds by their residents before and up to six months after the workshops. Behavior before and after the workshops was compared using a mixed model. RESULTS: A total of 374 reports were returned (77% response). After adjusting for the type of service and observer, there was a statistically significant 23% increase (P=.02) in the performance of physical examination among residents who attended the course. Residents significantly increased the fraction of patients they examined on rounds (absolute increase 11%, P=.002) but did not increase the depth of their examination. The change was greatest on general medical teams, among whom the performance of physical examination had been least frequent. Teaching and feedback events on medicine teams by residents to their interns (2.8 and 1.1 events per 2 weeks, respectively) and medical students (5.9 and 2.8 events per 2 weeks, respectively) remained infrequent. CONCLUSIONS: A skills improvement program can significantly increase the frequency of physical examination, but teaching and feedback events remain sporadic and infrequent.