The Feasibility of Longitudinal Patient Contacts in a Large Medical School

Problem: Longitudinal patient contacts are being implemented worldwide as a way to enhance a patient-centered orientation among medical students. In large medical schools, longitudinal integrated clerkships may not be feasible, so other ways must be sought to expose students to prolonged contact with patients. Intervention: Medical students were attached to a family practice and assigned a panel of 4 patients to follow over the 3 years of their clinical training. Their role was that of companion on the patient’s medical journey. The program consisted of several encounters, joining the patient in the medical setting for significant events, and written assignments. This intervention was piloted with 35 students. We describe our experiences from the 1st pilot year of this program. Context: The intervention was performed with 3rd-year students—of a 6-year curriculum—at a large medical school in the Netherlands. Outcome: Finding enough patients per practice was feasible. On the whole, students fulfilled the program’s expectations regarding frequency of patient encounters and assignments. The most frequent problems encountered by the students were uncertainty about their role and setting boundaries in their contact with the patients. They needed more preceptor supervision and coaching than they received. Lessons Learned: For junior students, close and structured supervision led by the faculty is necessary to help them navigate and learn from a panel of patients. Students need guidance about what role they should take on and on how to manage both their own and their patient’s expectations. Guided reflection is necessary to help students give meaning to their experiences with patients.     

Patient satisfaction with diabetes care

AIM: The aim of this paper is to report the findings of a study that elucidated the experiences and reflections of people with type 2 diabetes about clinical encounters. BACKGROUND: Several patient satisfaction surveys have focused on privacy, cheerfulness and amenities rather than on how the care was delivered. A great deal of research has also focused on communication and various consultation styles, particularly within health promotion and diabetes care, but how these factors tie up with patient satisfaction has rarely been discussed. This study was performed in order to elucidate patients' perspectives about clinical encounters in diabetes care. METHOD: Interviews were carried out during 2001 with 44 patients with diabetes. The transcribed interviews were analysed using qualitative content analysis. RESULTS: Five themes were connected to patient satisfaction and dissatisfaction, namely 'being in agreement vs. in disagreement about the goals'; 'autonomy and equality vs. feeling forced into adaptation and submission'; 'feeling worthy as a person vs. feeling worthless'; 'being attended to and feeling welcome vs. ignored'; and, lastly, 'feeling safe and confident vs. feeling unsafe and lacking confidence'. CONCLUSION: Despite efforts to individualize diabetes care and find ways to communicate with patients, many people have experiences of clinical encounters that they find dissatisfying. Experiences of dissatisfying encounters have elements that may threaten their perception of self and identity, while elements included in satisfying encounters are those characterizing patient-centred care.     

Is an educational lecture a critical component of communication partner training?

Abstract

Purpose: Little is known about the critical ingredients of successful Communication Partner Training (CPT) programmes. The aim of this randomised controlled trial was to investigate the effects of including an educational component before a conversation with a person with aphasia compared to a conversation only.

Method: Thirty-eight speech–language pathology students were randomly allocated to either the Full programme or Conversation only groups. The Full programme group received a lecture about communication strategies then participated in a conversation with a person with aphasia, while the other group participated in the conversation only. Both groups received feedback on performance from the people with aphasia. Students completed a customised mixed-methods questionnaire at study commencement and following the conversation.

Result: Generalised linear models indicated confidence ratings improved after receiving either the Full programme or Conversation only (p?<?0.001), however, greater improvements were observed following the Full programme (p?<?0.001). More communication strategies were identified after the interventions (p?=?0.001) with greater improvement occurring among the Full programme group (p?<?0.01).

Conclusion: An educational lecture before a conversation with a person with aphasia is a critical component of CPT programmes, enhancing their knowledge base and increasing their confidence levels compared to only a conversation.     

Teaching medical students about communication in speech-language disorders: Effects of a lecture and a workshop

Purpose: This study aims to explore the effects of an interactive workshop involving speech-language pathology students on medical students’ knowledge about communication in relation to speech-language disorders.

Method: Fifty-nine medical students received a lecture about speech-language disorders. Twenty-six of them also participated in a workshop on communication with patients with speech-language disorders. All students completed a 12-item questionnaire exploring knowledge and attitudes towards communication before and after the lecture or the workshop. The results from the two groups’ self-ratings of confidence in knowledge were compared with expert-ratings of their ability to choose suitable communicative strategies.

Result: Both the lecture and the workshop increased the students’ confidence in knowledge about speech-language disorders and how to support communication. Only the workshop group also displayed a statistically significant increase in expert-rated ability and changed their attitude regarding responsibility for the communication in cases of speech-language disorders. There were no statistically significant correlations between the student’s own confidence ratings and the experts’ ratings of ability.

Conclusion: Increased confidence in knowledge from learning is not always reflected in actual knowledge in how to communicate. However, an interactive workshop proved to increase medical students’ expert-rated ability and attitudes related to communication in cases of speech-language disorders.     

Assessing Advanced Communication Skills via Objective Structured Clinical Examination: A Comparison of Faculty Versus Self,Peer, and Standardized Patient Assessors

Abstract

Construct: The construct addressed in this study is assessment of advanced communication skills among senior medical students. Background: The question of who should assess participants during objective structured clinical examinations (OSCEs) has been debated, and options discussed in the literature have included peer, self, standardized patient, and faculty assessment models. What is not known is whether same-level peer assisted learning can be utilized for formative assessment of advanced communication skills when no faculty, standardized patients, or other trained assessors are involved in providing feedback. If successful, such an educational model would optimize resource utilization and broaden the scope of topics that could be covered in formative OSCEs. Approach: The investigators developed a 4-station formative OSCE focused on advanced communication skills for senior medical students, and evaluated the concordance of assessment done by same-level peers, self, standardized patients, and faculty for 45 students. After each station, examinees completed a self-assessment checklist and received checklist-based assessment and verbal feedback from same-level peers only. Standardized patients completed checklist-based assessments outside the room, and faculty did so after the OSCE via video review; neither group provided direct feedback to examinees. The investigators assessed inter-rater agreement and mean difference scores on the checklists using faculty score as the gold standard. Findings: There was fair to good overall agreement among self, same-level peer, standardized patient, and faculty-assessment of advanced communication skills. Relative to faculty, peer and standardized patient assessors overestimated advanced communication skills, while self-assessments underestimated skills. Conclusions: Self and same-level peer-assessment may be a viable alternative to faculty assessment for a formative OSCE on advanced communication skills for senior medical students.     

Patient Perceptions of Having 1st- and 2nd-Year Medical Students Involved in Their Care

Background: Medical student education has shifted to earlier clinical experiences and increased use of ambulatory settings. Little is known about patient perceptions of having 1st- and 2nd-year medical students involved in their care. Purposes: The purpose of this article is to study patient perceptions of having 1st- and 2nd-year medical students involved in their care in an ambulatory setting. Methods: In 2011 we surveyed 314 patients seen in 2 primary care clinics who saw 1st- or 2nd-year medical students. The survey included questions regarding patient visit satisfaction and perception of overall quality of the visit, adequacy of visit time, benefit of having a student involved in their care, and willingness to see a student in clinic again. Comparisons were made for patients who saw a student and a preceptor (n = 201) and patients who saw only the preceptor (n = 113). Results: Overall visit satisfaction was very high for patients who saw students (83% very satisfied) and patients who saw only the preceptor (91% very satisfied). More than 95% of patients were satisfied with the visit time, and all patients rated the overall quality of their visit as good or excellent. Eighty-five percent of patients would want to see a student again or had no preference. Forty-three percent of patients felt the presence of a student added value to their visit. White patients were more likely than non-White patients to be very satisfied with their visit and rated the overall quality of the visit as excellent. There were no differences based on student gender or year of training. Conclusions: Our results suggest that 1st- and 2nd-year students can be successfully integrated into clinical settings while maintaining patient satisfaction and perceived value of the care they receive.     

Using Patient Encounter Logs for Mandated Clinical Encounters in an Internal Medicine Clerkship

Background: Patient encounter logs help assess a student's educational experience. The use of a grading incentive linked to the mandatory documentation of prespecified clinical encounters has been insufficiently studied. Purposes: Given this, our objectives were to determine (a) if mandating student exposure to patients with 18 key training problems leads to the successful documentation of these encounters, (b) the degree of difficulty students and clerkship directors experienced in meeting these mandates, (c) the accuracy of mandated log entries, and (d) how often the log entries were questioned or rejected by preceptors. Methods: Ninety-two 3rd-year internal medicine students and 6 internal medicine clerkship directors at 9 geographically dispersed hospitals and 30 ambulatory sites participated in the study. Over a single academic year, we directly measured the completion rate of mandated logs, the degree of their accuracy as judged against faculty-generated logs of two required videotaped standardized patient encounters, and the percentage of logs that were not validated. We surveyed students and directors on the perceived degree of difficulty in meeting mandated requirements. Results: Ninety-eight percent of students met our mandated requirements and 93.8% of students found it “easy” or “very easy” to meet this requirement. The amount of estimated time spent by clerkship directors helping students meet mandated requirements for the entire year was 4.5 hr. The accuracy of submitted logs was 77%; however, almost all inaccurate log entries were “validated” by preceptors. Conclusions: Mandating encounters is effective in assuring that students document encounters with patients who present with specific clinical problems. The accuracy of our students' mandated logs is similar to previously published data. However, even inaccurate logs were rarely questioned or rejected by preceptors.     

The Impact of Trainee Nationality on Patient Acceptance of Obstetrics and Gynecology Care: A Chinese Study

Abstract

Phenomenon: China is a relatively homogenous nation where the majority of people are Han Chinese. In recent years, a large number of international students have begun to study medicine in China. Due to the privacy and intimacy associated with obstetrical and gynecological diseases, Chinese women’s acceptance toward international students’ involvement in their care has not been reported thus far. This survey aims (1) to determine Chinese women’s attitudes toward both Chinese and international medical student involvements in obstetrical and gynecological outpatient departments and (2) to investigate possible reasons, if any, for their rejection of the medical students. Approach: We conducted a cross-sectional survey study using a locally-developed questionnaire. The survey was conducted in the obstetrical and gynecological outpatient department of a tertiary hospital in a Chinese harbor city. We surveyed 600 patients for their attitudes towards the involvement of four groups of medical student in clinical practice: Chinese female, International female, Chinese male, and International male. Among the returned questionnaires, 501 satisfied the criteria for analysis. Findings: Patient’s acceptance rates of the four groups of students (Chinese female, International female, Chinese male, and International male) were 59.7%, 55.9%, 32.1%, and 25.9%, respectively. Analysis revealed that language barriers and lack of friendliness were the two main reasons leading to patients’ low acceptance rates of international students. Insights: Obstetrical and gynecological patients are more likely to accept female students over male students, regardless of their nationality, however International male students receive the least acceptance. For international students, improving their Chinese language skills and using more friendly expressions may facilitate their practice in China.     

Improving medical students’ knowledge and skill in communicating with people with acquired communication disorders

Purpose: To explore the effects of an interactive workshop on medical students’ knowledge and skill in communicating with people with acquired communication disorders.

Method: Sixty-nine medical students received a lecture on acquired communication disorders. Thirty-six of these students also participated in a workshop where they practised using supportive strategies in interaction with a simulated patient with aphasia. All students completed a questionnaire exploring attitudes, confidence in knowledge and ability to suggest suitable supportive strategies pre- and post-lecture/workshop and 15 students were video recorded when interacting with a simulated patient pre- and post-workshop.

Result: The results show no change in attitude in either student group, but both groups rated their confidence in knowledge as higher post-lecture/workshop. The students’ ability to suggest supportive strategies post training was significantly higher only in the workshop group. Comparing post training results regarding knowledge and ability to suggest supportive strategies between the groups, higher ratings were found for the workshop group. The analysis of video recordings indicated that the students also used new supportive strategies and used strategies more frequently after the workshop.

Conclusion: An interactive workshop can improve medical students’ knowledge and skills in communicating with people with acquired communication disorders.     

Lesbian,Gay, Bisexual,and Transgender Patient Care: Medical Students' Preparedness and Comfort

Phenomenon: Lesbian, gay, bisexual, and transgender (LGBT) individuals face significant barriers in accessing appropriate and comprehensive medical care. Medical students' level of preparedness and comfort caring for LGBT patients is unknown. Approach: An online questionnaire (2009–2010) was distributed to students (n = 9,522) at 176 allopathic and osteopathic medical schools in Canada and the United States, followed by focus groups (2010) with students (n = 35) at five medical schools. The objective of this study was to characterize LGBT-related medical curricula, to determine medical students' assessments of their institutions' LGBT-related curricular content, and to evaluate their comfort and preparedness in caring for LGBT patients. Findings: Of 9,522 survey respondents, 4,262 from 170 schools were included in the final analysis. Most medical students (2,866/4,262; 67.3%) evaluated their LGBT-related curriculum as “fair” or worse. Students most often felt prepared addressing human immunodeficiency virus (HIV; 3,254/4,147; 78.5%) and non-HIV sexually transmitted infections (2,851/4,136; 68.9%). They felt least prepared discussing sex reassignment surgery (1,061/4,070; 26.1%) and gender transitioning (1,141/4,068; 28.0%). Medical education helped 62.6% (2,669/4,262) of students feel “more prepared” and 46.3% (1,972/4,262) of students feel “more comfortable” to care for LGBT patients. Four focus group sessions with 29 students were transcribed and analyzed. Qualitative analysis suggested students have significant concerns in addressing certain aspects of LGBT health, specifically with transgender patients. Insights: Medical students thought LGBT-specific curricula could be improved, consistent with the findings from a survey of deans of medical education. They felt comfortable, but not fully prepared, to care for LGBT patients. Increasing curricular coverage of LGBT-related topics is indicated with emphasis on exposing students to LGBT patients in clinical settings.     

Teaching Delivery of Bad News Using Experiential Sessions With Standardized Patients

Background: Delivering bad news is a difficult task that is important to address in medical education.

Purpose: This study evaluated the impact of an experiential educational intervention using multiple standardized patient scenarios on medical students' comfort with delivering difficult news.

Methods: In small groups, 3rd-year medical students practiced communicating bad news within the context of five different patient scenarios. During 1999 and 2000, surveys were administered to 341 students before and 4 weeks and 1 year after the program. Students rated comfort level in discussing bad news, terminal illness, hospice, and dying with patients.

Results: A significant one standard deviation change was observed in students' self-reported comfort in communicating bad news after the educational program. The intervention was highly rated, especially the encounters with standardized patients and observation of others.

Conclusions: Experiential education using multiple standardized patient scenarios is a successful model for increasing student comfort in responding to difficult clinical communication tasks     

Undergraduate nursing students’ experiences of practicing caring behaviours with standardised patients

Rationale

Undergraduate nursing students’ learning opportunities to practice caring behaviours to assure compassionate and competent nursing practice with standardised patients are few. Earlier studies primarily focused on practicing communication skills in relation to mental health or developing psychomotor skills while caring for a patient with a specific diagnosis.

Aim

The study aim was to describe undergraduate nursing students’ experiences of practicing caring behaviours with a standardised patient.

Method

A sample of forty-eight undergraduate nursing students in semester four at a school of nursing in southern Sweden, enrolled in a full-time, 5-week, on-campus elective caring behaviour course, were at the first and last week individually video-recorded during two caring behaviour simulations encountering a standardised patient. After observing each of their video-recordings, students completed written reflections focusing on their own compassionate and competent verbal and nonverbal caring behaviour. In total, 96 individual written reflections were analysed using qualitative content analysis to describe the experience.

Results

One main theme emerged: The challenge of being mindfully present in patient encounters. Four themes further described the experience: A challenging but realistic learning experience, learning the impact of nonverbal behaviour, recognising the complexity of verbal behaviour, and learning to be with the patient instead of only doing for the patient.

Conclusion

When caring is intertwined with visible and realistic nursing practice in simulations using standardised patients it facilitates undergraduate nursing students learning compassionate and competent caring behaviour. The learning experience opened the students’ eyes to the impact of practicing caring, recognising that being with is not the same as doing for the patient, and thus, how challenging it is to be mindfully present in patient encounters. Designing caring behaviour simulations with standardised patients is a feasible and efficacious educational learning didactic to facilitate students’ learning caring behaviour and enhancing patients’ experiences.     

Student nurses’ experiences of communication in cross‐cultural care encounters

Scand J Caring Sci; 2010; 24; 436–444
Student nurses’ experiences of communication in cross‐cultural care encounters Background: Communication is a fundamental component of cross‐cultural care encounters. Nurses experience communication difficulties in situations where they do not speak the same language as their patients. Communication difficulties are a major obstacle for immigrant patients and can lead to insufficient information and poor quality nursing care in contrast to the majority population. Aim: To explore student nurses’ experiences of communication in cross‐cultural care encounters. Methods: Semi‐structured interviews were undertaken a purposive sample of 10 final year students from one university in Sweden: five participants were from a Swedish background and five from an immigrant background. Interviews explored participant’s experiences of communication in cross‐cultural care encounters. Interviews were tape recorded, transcribed and analysed using ‘framework’ approach. Results: Four themes were identified: conceptualizing cross‐cultural care encounters, difficulties in communication, communication strategies and factors influencing communication. ‘Culture’ was equated with country of origin. Cross‐cultural care encounters involved patients from a different immigrant background to the nurse. Student nurses experienced particular difficulties communicating with patients with whom they did not share a common language. This led to care becoming mechanistic and impersonal. They were fearful of making mistakes and lacked skills and confidence in questioning patients. Various strategies were used to overcome communication barriers including the use of relatives to interpret, nonverbal communication, gestures and artefacts. Other factors which influenced communication included the student’s attitude, cultural knowledge acquired through education and life experience. Conclusion: Although student nurses seek creative ways to communicate with patients from different cultural backgrounds they lack skills and confidence in cross‐cultural communication. Nursing programmes need to address this deficit to ensure that nurses are equipped with the knowledge and skills to provide quality care to patients from different cultural backgrounds.     

Increasing Patient Acceptance of Medical Student Participation: Using Interactive Theatre for Faculty Development

Background : Interactive theatre (IT) has been used to train faculty the skills and strategies to address challenging dynamics in educational settings. Purpose : This study described the development, implementation, and evaluation of an IT approach to improve preceptors' skills for increasing patients' acceptance of medical student participation in clinical care. Methods : Focus groups were conducted with faculty, residents, medical students, and clinic staff to discuss issues related to patients declining medical student participation. Findings were used to develop a faculty development session using an IT approach. At a Family Medicine grand rounds presentation, faculty and resident preceptors (n = 42) participated in the IT workshop and completed a pre–post survey assessing skills specific to increasing students' training opportunities in patient care and educational impact of the session. Results : Following the IT session, preceptors reported greater self-efficacy for helping patients feel more comfortable with medical students in the exam room (p =.031, d = 0.338) and increased comfort level with talking to patients about medical students performing sensitive exams (p =.010, d = 0.357). Eighty-eight percent of preceptors agreed or strongly agreed that the session was relevant to improving clinical precepting skills and helped them develop strategies for enhancing medical student involvement in care. Conclusions : Findings suggest that the interactive theatre approach to faculty development is an innovative and effective method to increase preceptors' comfort with discussing medical student involvement with patients.     

Patient Concerns about Medical Errors in Emergency Departments

OBJECTIVE: Despite large numbers of emergency encounters, little is known about how emergency department (ED) patients conceptualize their risk of medical errors. This study examines how safe ED patients feel from medical errors, which errors are of greatest concern, how concerns differ by patient and hospital characteristics, and the relationship between concerns and willingness to return for future care. METHODS: Multiwave telephone interviews of 767 patients from 12 EDs were conducted. Patients were asked about their medical safety, concern about eight types of medical errors, and satisfaction with care. RESULTS: Eighty-eight percent of patients believed that their safety from medical errors had been good, very good, or excellent; 38% of patients reported experiencing at least one specific error-related concern, most commonly misdiagnosis (22% of all patients), physician errors (16%), medication errors (16%), nursing errors (12%), and wrong test/procedure (10%). Concerns were associated with gender (p < 0.01), age (p < 0.0001), ethnicity (p < 0.001), length of stay (p < 0.001), ED volume (p < 0.0001), day of week (p < 0.0001), and hospital type (p < 0.0001). Concerns were highly related to a patient's willingness to return to the ED. CONCLUSIONS: The majority of ED patients felt relatively safe from medical errors, yet a significant percentage of patients experienced concern about a specific error during their emergency encounter. Concerns varied by both patient and hospital characteristics and were highly linked to patient satisfaction. The selective nature of concerns may suggest that patients are attuned to cues they perceive to be linked to specific medical errors, but efforts to involve patients in error detection/prevention programs will be challenging given the stressful and intimidating nature of ED encounters.     

Facilitating employment opportunities for adults with intellectual and developmental disability through parents and social networks

Purpose: People with intellectual and developmental disability (IDD) have historically had high unemployment and underemployment rates and continue to face significant barriers to attaining and sustaining employment. The purpose of this research, conducted in Ontario, Canada was to better understand the experiences of people with IDD gaining and keeping productivity roles. Method: We used qualitative semi-structured interviews with 74 participants with IDD and their families or caregivers as proxies regarding the employment of a person with IDD. We selected a sample of persons from three different geographic regions in Ontario, Canada, and analyzed data through coding methods consistent with a grounded theory approach. Results: Our results demonstrate the importance of parents and other members of social and family networks relative to connecting with work options and sustaining work over time, especially through continued advocacy and investment. Parents helped individuals with IDD negotiate the right job fit, though they often encountered challenges as a result of their efforts. Conclusion: Practitioners must understand how to support parents to be effective advocates for their adult children with IDD, assist them to develop and maintain their social networks and help them to avoid caregiver burnout.

• Implications for Rehabilitation

• People with intellectual and developmental disability (IDD) face numerous challenges in indentifying work options and overcoming barriers to employment.

• Parents and other non-paid support members of social networks can be instrumental in ensuring that persons with IDD not only secure initial job placements, but also sustain employment and employment alternatives.

• Professionals that support persons with IDD can direct their efforts to helping persons with IDD develop strong social connections, as well as helping parents to prevent burnout.