Teaching systems-based practice to residents by using independent study projects.

The changing health care marketplace requires new graduates to be familiar with complex health systems. Since 1999 the Oregon Health & Science University internal medicine residency program has offered a seminar-based health systems curriculum, but residents lacked an opportunity to actively apply learned concepts. To achieve this goal, the authors developed a second curricular component, the Health Systems Independent Study Project (HSISP). The HSISP is a self-directed assessment of a health care system or delivery issue residents complete in their third year. The curriculum was implemented in 2001 with goals of gaining a focused understanding of a health systems concept and building related skills. Residents present their study projects to all curriculum participants. Topics addressed so far include adherence to coronary artery disease guidelines in a defined population, screening strategies for lung cancer, resident burnout, and many others. Residents have found that these projects enhance their systems knowledge, help them link systems-based-practice concepts to clinical practice, and foster opportunities for networking and early career development.     

Teaching medical residents about teenagers: an introductory curriculum in adolescent medicine.

OBJECTIVE: Adolescents in the United States have high morbidity rates, which are attributable to injuries, behavioral disorders, sexually transmitted diseases, and unplanned pregnancies. This has led to a call to action for health care educators to better prepare future practitioners to meet adolescent health care needs. Although pediatrics residency programs have required one-month curricula dedicated to adolescent medicine, many internal medicine (IM) residency programs do not have such requirements despite an American College of Physicians position paper recognizing the importance of internists' providing health care to adolescents. Thus, an introductory curriculum in adolescent medicine was developed for a community hospital IM residency program. The curriculum was designed to train IM residents to effectively interview, provide preventive care for, and evaluate common medical problems of older adolescents (ages 16-21) in an outpatient setting. DESCRIPTION: The curriculum was based on the results of an extensive needs assessment, which included surveys sent to practicing internists and current IM residents. It included three units, each a series of one-hour lessons delivered via morning report or grand rounds sessions. The first unit was interviewing, which covered specific interviewing questions, communication methods, and confidentiality issues. The second unit was preventive medicine care, which addressed immunizations, injury prevention, and adolescent drug and alcohol use. The third unit was diagnosis and management of common problems, which focused on topics frequently encountered during adolescent outpatient visits, including acne, sexually transmitted diseases, reproductive health care needs, and menstrual abnormalities. Other topics pertinent to the care of adolescents, notably depression, eating disorders, and sports medicine, were covered by previously established curricula, and thus omitted. This curriculum was created through the support of the Michigan State University Primary Care Faculty Development Fellowship Program, and was reviewed by curricular and adolescent medicine content experts. The residency program director supported its implementation over the course of two academic years. The pilot unit interviewing was conducted in February 2001, during two one-hour morning report sessions. In the first session, a short lecture outlining interviewing concepts and principles was given, followed by several case-based studies describing office presentations of adolescent patients. In the second session, an actual office visit was simulated; the residents observed adolescent volunteers being interviewed, and were then given an opportunity to ask the patients further questions. Residents completed a brief quiz and evaluation survey at the end of the pilot unit. DISCUSSION: Twenty-one of 40 residents participated in the pilot unit. Evaluations were overall very positive. Quiz scores confirmed that the residents achieved the desired learning objectives. Given these results from the pilot unit, the remaining two units of the curriculum have been integrated into the residency curriculum. Additional faculty members have been selected to deliver future sessions and support this important educational activity. The adolescent medicine curriculum can be used as an model by other IM residency programs for teaching adolescent health care, with an emphasis on both the knowledge base of adolescent issues and awareness of the unique skills necessary for the establishment of a physician-patient relationship between internists and older adolescents.     

A prospective study of internal medicine residents' emotions and attitudes throughout their training

To evaluate whether the negative emotions and attitudes that residents develop during internship continue throughout the remaining years of their residency, the authors undertook a four-year prospective study of two classes of internal medicine residents who completed their training in 1985 and 1986 in a residency program based at the Oregon Health Sciences University. Every two to three months over all three years of training, the residents indicated on Likert-type scales their levels of agreement with questions about their career satisfaction and emotional states, and the satisfying and dissatisfying aspects of their residency experiences. Between the internship and the end of their residencies, the physicians indicated significant improvements in their emotions and attitudes. Those experiences identified as satisfying continued to be so, whereas those considered dissatisfying became less so. Although more research of other classes of residents is needed, the findings suggest that while internal medicine internships may be dysphoric, the residents' emotional states and attitudes tend to normalize during the remainder of the residency.     

Part-time residency training in internal medicine: analysis of a ten-year experience.

PURPOSE: To evaluate a ten-year experience (1983-1993) with a part-time residency curriculum. METHOD: In 1994, the authors analyzed the curriculum through interviews with graduates of a part-time residency track, surveys of faculty and graduates of a full-time residency program, and a quantitative comparison of faculty evaluations of those part-time and full-time residents. RESULTS: Both participants and full-time residents supported the part-time track and reported no adverse effect on the residency program as a whole. Analysis of faculty evaluations found that part-time residents scored significantly higher with respect to clinical skills (p = .0005) and humanistic skills (p = .0001), while there was no difference between the groups in leadership or teaching skills. CONCLUSIONS: This part-time residency curriculum provided a highly useful program track for a group of internal medicine residents with concomitant obligations, allowing them to complete their training in an uninterrupted fashion. The part-time structure did not adversely affect clinical competence and may have fostered humanistic attributes. The authors believe that this form of curriculum deserves wider consideration in residency training.     

Community partners as co-teachers in resident continuity clinics

Standard approaches to teaching the management of psychosocial issues in pediatrics--visits to community-based organizations and stand-alone block rotations in developmental-behavioral pediatrics and community pediatrics--neither expose residents to models of interdisciplinary collaboration between faculty preceptors and community providers nor take advantage of the efficacy of learning in continuity clinics. The authors describe their project, developed from an existing Community Pediatrics Training Initiative with long-standing relationships with a domestic violence shelter, a community center for Latino families, and a special needs resource organization for parents. They lay out in detail the project's innovative use of partners from community-based organizations, colocated within pediatric continuity clinics, who teach both residents and faculty about community resources and linkages with multidisciplinary providers. The authors present lessons learned by faculty preceptors, residents, the community partners, and project staff that can guide future applications of this model in other residency training programs. Faculty and residents indicated an increased awareness of available community resources and how linkages can be incorporated into pediatric outpatient visits. Community partners identified keys to successful co-teaching, including readiness to adopt an assertive communication style and frequent presence in the clinics. Project staff recognized the challenges of staff turnover at community-based organizations and the need to choose community partners with expertise that fits the sociodemographic issues of the clinic's patients.     

The development of a medical ethics curriculum in a General Internal Medicine Residency Program

Since 1984, a three-year curriculum in medical ethics has operated at Rhode Island Hospital as part of the General Internal Medicine Residency Program at the Rhode Island Hospital and Brown University. The residency program was founded in 1980 to develop a model training program for internal medicine residents with a primary care focus. The three objective of the curriculum are (1) to enable residents to recognize the ethical implications of both inpatient and outpatient clinical cases, (2) to teach residents to recognize ethics issues and alternatives in order to arrive at a well-rounded clinical strategy, and (3) to help them learn to communicate sensitively with patients and others about these ethics issues and proposed management plans. The six major topics covered by the curriculum (for example, informed consent) are co-taught in a seminar format by one or more of the three members of the multidisciplinary ethics faculty (a philosopher, an internist, and a communications specialist) and experienced physicians. The authors describe the program, the roles of the various faculty members, the program's focus on case discussions, the receptivity of the residents and faculty to the program, the use and training of a multidisciplinary faculty, efforts aimed at evaluation, and future directions of the program.     

Introducing residents to a career in management: the Physician Management Pathway.

To prepare their students and residents for the practice of medicine in a rapidly changing environment, medical educators must teach the business of medicine as well as the science and art of medicine. Recognizing the value of and demand for physician leaders, the authors sought to introduce residents to diverse aspects of medical administration within the context of an academically rigorous internal medicine residency program. The Physician Management Pathway (PMP) was developed in 1997 to expose interested residents to the management concepts employed by physician managers; to help physician trainees begin to develop the leadership and technical skills they will use as physician managers; to provide career mentoring; to provide experiences that enrich the resident's training in clinical medicine; to enhance resident-directed educational activities; and to produce physicians who can successfully work in any health care environment. The PMP curriculum consists of a monthly seminar series, a preceptorship experience in the second year of residency, and a supervised project in the third year. The program was not designed to provide competency in management, but rather is intended to provide an opportunity for new physicians to explore options in this exciting and changing profession.     

Teaching and improving quality of care in a primary care internal medicine residency clinic.

Purpose Learning and applying quality of care principles are essential to practice-based learning and improvement. The authors investigated the feasibility and effects of a self-directed curriculum in quality of care for residents. Method In 2001-02, 13 second-year residents at two community-based outpatient clinics in the Yale University primary care internal medicine residency program were asked to participate in a trial of a quality improvement curriculum (intervention group). Thirteen third-year residents in the same residency program served as the comparison group. The curriculum consisted of readings in quality of care, weekly self-reflection with a faculty member, completion of a commitment to change survey, and medical record audits. Study outcome measures were patient level quality of care measures for diabetes, satisfaction with the curriculum, and self-reported behavioral changes. Results In the follow-up, patients of the intervention group were significantly more likely to have received a monofilament foot examination and baseline electrocardiogram than were patients of the comparison group. When comparing the change between baseline and follow-up, patients for the second-year residents showed significantly more improvement in hemoglobin A1c and LDL cholesterol levels and Pneumovax administration than did patients of the comparison group. All residents in the intervention group were highly satisfied with the curriculum. Thirty-five of 54 residents' personal commitments to change were either partially or fully implemented six months after the curriculum. Conclusions A multifaceted curriculum in quality improvement led to modest improvements in the care of diabetic patients and meaningful changes in self-reported practice behaviors. Future research should include more focus on the microsystems of residency outpatient experiences.     

How a community-based organization and an academic health center are creating an effective partnership for training and service.

Community-academic partnerships in the training of doctors offer unique learning opportunities of great importance. Such partnerships can induce a paradigm shift such that physicians view community as a teaching resource and partner rather than as a passive recipient of services or solely as a placement site. The authors describe a model of a community-academic partnership in New York City, begun in 1995, in which, for training and service, pediatric residents are integrally involved in a community-based program. Principles adapted from the Community-Campus Partnerships for Health's principles of partnership provide a framework for portraying the essential elements of developing and maintaining the partnership. The authors explain the clashes that may arise between partners and show how the principles of partnership guide partnership members in working and learning within a setting that by its nature entails conflict and inequality. This report is based on the knowledge gained from the structured reflections of both members of this partnership: the residency program at a large academic health center and the community-based social service organization. Such partnerships provide the training ground for the development of physicians who understand the social and cultural determinants of health and constructively use community agencies' input in promoting child health and well-being. Within this framework, community-based organizations are not solely service providers but become educators of physicians-in-training who, with new knowledge gained through the partnership, more effectively contribute to the overall health of the communities they serve.     

Hospital to home: Improving internal medicine residents' understanding of the needs of older persons after a hospital stay.

Physicians-in-training discharge many older patients from the hospital, but few have any knowledge of what happens to the patients they send home, of how discharge plans are applied, or of the difficulties patients and their families face. The authors describe a pilot program, Hospital to Home, at the University of Rochester School of Medicine and Dentistry's internal medicine residency program, which uses home visits as an educational tool in geriatrics training. The program was begun in July 2001, and 23 residents have participated. Home visits expose residents in their first-year geriatrics rotation to the elements and outcomes of discharge planning and create a heightened awareness of the needs of older persons recently discharged from the hospital. The home visits are videotaped, and the residents present a videoconference based on the visits, which are attended by internal medicine residents, family medicine residents, and medical students. The authors describe the three-part Hospital to Home program, three vignettes that highlight learning experiences, and the residents' feedback about the experience and the use of audiovisual recording for education.     

Teaching professionalism within a community context: perspectives from a national demonstration project.

Most medical schools now include some component of professionalism in their curriculum, ranging from "white coat" ceremonies to didactic and small-group, case-based discussions. Often this format does not provide a context for the course content nor does it necessarily make the curricular themes relevant to population groups and communities most vulnerable to the inequities and injustices present in health care. The authors describe a community-based professionalism curriculum for preclinical and clinical year medical students and report evaluation data from three years (2001-2003) of this national demonstration project. The curriculum emphasized four themes: service, community, advocacy, and ethical behavior and was based on a service-learning pedagogy applied within community-based organizations. As part of the program evaluation, 95 students from 33 medical schools between the years 2001 and 2003 (response rate: 84.8%) completed an anonymous questionnaire. When asked what did they learn about professionalism that they did not learn (or expect to learn) in their medical school curriculum, the most common themes were (1) factors and influences affecting professional behavior, with many specifically citing pharmaceutical companies and insurance carriers (46.3%); (2) the role and importance of physician advocacy on behalf of their patients (37.9%); and (3) issues specific to the needs of vulnerable and disadvantaged populations (20.0%). This project demonstrates that community-based experiences can provide unique and relevant learning in a professionalism curriculum that can complement existing medical-school-based efforts.     

A systematic approach to faculty development in Women's health: lessons from education, feminism, and conflict theory.

The authors present a strategy for residency faculty development in women's health, the reasons that such a strategy is necessary (e.g., women's health encompasses much more than reproductive and disease issues, and is cross-disciplinary and intrinsic to all of family practice), and their residency program's experience with its development and implementation from 1994 to the present. In creating the program, the residency program's faculty used as a context some lessons learned from family medicine, since the rapid growth of family medicine provides a historical example of dealing with a critical shortage of faculty for new residency programs and the need for a new way to train educators. Also, the faculty reviewed the literature about faculty development in medicine, models of teaching and learning from women's studies, and group theory, specifically the skills concerning conflict and diversity. They used the salient elements from each (which the authors outline) in fashioning their new faculty development program. The resulting program also grew out of focus groups with patients, input from staff, residents, and faculty, and meetings and workshops, including some intense and highly charged discussions in which the faculty participants, both men and women, confronted their own views and biases and worked hard to successfully forge a common and relevant vision of women's health. The program has fostered faculty who are knowledgeable about the diverse educational skills required to teach women's health. They use these skills in all curricular content, thus demonstrating a new way to educate residents as well as faculty.     

The integrative family medicine program: an innovation in residency education.

The Integrative Family Medicine (IFM) Program is a four-year combined family medicine residency program and integrative medicine fellowship. It was created in 2003 to address the needs of four constituencies: patients who desire care from well trained integrative physicians, physicians who seek such training, the health care system which lacks a conventional integrative medicine training route, and educational leaders in family medicine who are seeking new strategies to reverse the declining interest in family medicine amongst U.S. graduates. The program was designed jointly by the University of Arizona Program in Integrative Medicine (PIM) and family medicine residency programs at Beth Israel/Albert Einstein College of Medicine (AECOM), Maine Medical Center, Middlesex Hospital, Oregon Health & Science University, and the Universities of Arizona and Wisconsin. One or two residents from each of these institutions may apply, and when selected, commit to extending their training by a fourth year. They complete their family medicine residencies at their home sites, enroll in the distributed learning associate fellowship at PIM, and are mentored by local faculty members who have training in integrative medicine. To date three classes totaling twenty residents have entered the program. Evaluation is performed jointly: PIM evaluates the residents during residential weeks and through online modules and residency faculty members perform direct observation of care and review treatment plans. Preliminary data suggest that the program enhances interest amongst graduating medical students in family medicine training. The Accreditation Council of Graduate Medical Education Family Medicine residency review committee has awarded the pilot experimental status.     

Developing an interdisciplinary, community-based education program for health professions students: the Rochester experience.

To successfully meet the nation's changing health needs, future health professionals must learn skills in applied health promotion and disease prevention. To achieve these goals, the Center for Rochester's Health (the Center), a collaboration of the Monroe County Department of Public Health and the University of Rochester School of Medicine and Dentistry and School of Nursing, all located in Rochester, New York, developed an innovative education program that gives interdisciplinary teams of students opportunities to partner with community agencies engaged in research-oriented health improvement initiatives. The Center started this course in 1998, under the auspices of a national initiative supported by the Health Resources and Services Administration and the Institute for Healthcare Improvement. The authors discuss the challenges related to the implementation and institutionalization of this interdisciplinary population-based education program. They describe their experiences over a seven-year period, from 1998 to 2005, including the various factors that enabled them to make necessary changes in the program activities and the ways in which the Center was able to bring departments together to consider new course directions for engaging students in the community health improvement process. They discuss the different stages of program development, including the early years of program planning and later curriculum changes that involved the development of an online population health curriculum. The authors conclude that by understanding changes in the education goals of various health professions schools and by adapting education programs to meet the needs of students from these schools, program planners will have more opportunities to sustain community-based education programs.     

Internal medicine residents' preferences regarding medical ethics education

Three hundred and twenty-three residents in six internal medicine programs in three states were surveyed concerning what they wanted to learn about medical ethics and how they would prefer to learn it; they were also asked to indicate what medical ethics education they had already received. Specifically, the residents were given a list of 35 medical ethics topics and asked to indicate whether they would like more attention to a topic, or whether it had received enough or too much attention. (They could also indicate that they though the topic was inappropriate for attention during residency.) The residents were also given a list of 17 teaching methods for medical ethics and asked to indicate whether each method was very useful, somewhat useful, or not useful. Sixty-one percent of the residents responded. Approximately three-fourths of these had had some formal teaching about medical ethics in both medical school and residency, and nearly all indicated that they wanted more ethics training on specific topics. Certain topics were chosen as particularly suitable or unsuitable for such training; many of those judged as deserving more attention concerned legal issues and end-of-life issues. Most of the responding residents regarded standard clinical teaching formats as very useful for learning about medical ethics but regarded several other methods are not useful. The authors discuss the implications of these and related findings.     

Mood change and empathy decline persist during three years of internal medicine training.

PURPOSE: To examine longitudinal changes in mood and empathy over the course of the internal medicine residency. METHOD: The authors conducted a cohort study of 61 residents who completed the Profile of Mood States (POMS) and the Interpersonal Reactivity Index (IRI) at six time points during their internal medicine residency at a university-based program. (POMS was administered five times, and IRI was administered six times.) The main outcomes measured were trends in mood disturbances and multiple domains of empathy over the three-year residency, and comparisons to norms. RESULTS: Response rates varied from Time 1 to Time 6 (98%, 72%, 79%, 79%, 94%, and 95%, respectively). Interns had better scores on four POMS subscales: Depression-Dejection (p = .0031), Anger-Hostility (p < .0001), Fatigue-Inertia (p < .0001), and Vigor-Activity (p < .0001) compared with later administrations, especially midinternship. By the end of residency all POMS scores were returning towards baseline (effects sizes in the .20 s), but only depression was no longer significantly different. IRI scores showed the decline in Empathic Concern remained over residency whereas Personal Distress peaked midinternship year but approached baseline at the end of residency. Compared with the general population, the graduating residents were less tense, depressed, and confused. Personal Distress was significantly lower than the norm group. CONCLUSIONS: Internal medicine residency presents challenges resulting in common mood disturbances. Although graduating residents appear to be better off than the population norms, some domains of their mood disturbances and empathy never fully recover from their internship year.     

Integration of women's health into an internal medicine core curriculum for medical students.

The authors describe their year-long collaboration to analyze and integrate the elements of women's health into their medical school's core curriculum in internal medicine for the third-year clerkship. Such a process was necessary because the current curriculum was inadequate in its treatment of women's health (e.g., little or no coverage of issues pertaining to women in teaching about certain disorders; lack of female subjects in many research studies; study designs' using standards derived from manifestations of diseases in men; the cross-discipline aspects of women's health). The authors illustrate the new curriculum by discussing the revised module in pulmonary medicine; they detail the steps they took to uncover problems and omissions in the existing curriculum and in the literature on the topic, and how they remedied these. (For example, in a case involving a man with pulmonary embolus, one of the new questions for students is "What questions would you ask if this patient were a woman?") They comment on the challenges they faced in revising the curriculum, including lack of protected time, lack of sufficient data about women's health, inherent sex and gender bias in the literature and educational materials, need to make students aware of the importance of sex and gender considerations in patient care, and the ingrained bias of faculty, including the authors. Their process can be adapted and used to integrate curricula in other emerging interdisciplinary fields, such as cross-cultural medicine and gay and lesbian health. The authors conclude that collaboration between students and faculty, as illustrated in their own efforts, is one way to ensure that future practitioners are optimally trained to treat patients in the ever-changing field of medicine.