8 The Observed Teaching Encounter: Providing Residents Feedback on Their Teaching Skills

Introduction:  Emergency medicine residents spend a significant portion of their time teaching junior residents and medical students in the clinical setting. Feedback is an integral component of any teaching curriculum, and therefore, feedback on residents' skill in teaching abilities is an essential part of their learning to teach. We have developed a structured method of providing feedback to senior residents on their teaching competence.
Methods:  Upcoming senior residents receive an 8-hour course on clinical teaching during their useful conference time. In our ED, attending faculty and senior "teaching" residents are matched with medical student learners. The Observed Teaching Encounter (OTE) is used during usual clinical ED shifts to reinforce concepts in teaching. During the OTE, the teaching resident is directly observed by a faculty physician while teaching a student learner. A checklist is completed by both the faculty member and the student learner in order to provide feedback to the teaching resident. Assessed skills correlate with teaching theory provided to residents in their didactic curriculum. Written formative comments are provided to the resident from faculty, as well.
Results:  Attending faculty, senior residents, and student learners have all provided positive feedback on the OTE. Assessment of residents' retention of knowledge on methodology of teaching is presently in progress as a tool to evaluate the efficacy of the OTE.     

7 Layered Simulation: A Novel Approach to Medical Malpractice Education

Overview:  We present a novel approach to the use of simulation in medical education with a two-event layered simulation. A patient care simulation with an adverse outcome was followed by a delayed simulated deposition.
Process:  Senior residents in an academic emergency medicine program were solicited as simulation research volunteers. Other than stating that the research involved adverse outcomes, no identifying information was given. Seven volunteers participated in a simulation involving a forced error (nurse confederate gave an incorrect medication dose). Based on the initial simulation, one physician completed a simulated deposition in a teaching conference six weeks later conducted by a licensed attorney with malpractice experience. The audience, consisting of residents, attendings, and students, watched a recording of the patient care, witnessed the deposition, and evaluated the experience using a 13 question survey with five-point Likert scales.
Outcome:  Participants felt that, overall, the training program was a useful educational tool (average Likert score of 4.63) that would change aspects of their practice (3.31). Participants stated that they would be more careful in their documentation (3.88), review high risk situations with staff (4.00), and monitor more carefully for errors (3.95). Overall, there was a degree of increased fear of the litigation process (3.95), but participants felt they would improve the risk profile of their practices (3.70).
Conclusion:  A novel approach to medical education was successful in changing attitudes and provided an expanded educational experience for participants. Layered simulation can be successfully incorporated into educational programs for numerous issues including medical malpractice.     

18 Graduate Medical Education and Knowledge Translation: One Problem-Specific Approach in Residency

Traditional graduate medical education approaches to improving clinical performance based upon the latest research have included Journal Club and didactic lectures. Unfortunately, these educational interventions have rarely been demonstrated to change practice behavior or improve patient-important outcomes. Using a structured approach to identifying a gap between best-evidence knowledge and clinical practice, an illustrative one-year residency-wide translational research project was developed in a four year emergency medicine training program. Step one (assigned to the second year residents): identify and quantitatively justify a Knowledge Translation (KT) deficit within our institution. They identified steroids in adult bacterial meningitis as an unequivocal therapeutic option. Based upon a structured one-year chart review, they next demonstrated that only 7% of meningitis patients received pre-antimicrobial steroids. The next step (assigned to the first year residents): identify and quantify the physician "leaks" within the pipeline of information from publication to bedside utilization via an online survey. The third year residents hypothesized plugs for these information leaks, including examples of other specialties or institutions which have successfully navigated this specific clinical scenario. Finally, at an end-of-year Journal Club, the fourth year residents formulated a protocol for the appropriate use of steroids in suspected adult meningitis and brought together individuals from within the institution contributing to the best-practice leak. Knowledge Translation involves multiple stages beyond simple evidence awareness and usually involves continuation beyond the emergency department. The Washington University KT project offers a structured, multidisciplinary example of moving beyond contemplation to implementation of an unequivocal therapy.     

4 A Multimedia Web-based Interactive Quiz Module for the Education of Emergency Medical Personnel

A dynamic database-driven website was introduced in 2002. This site has served successfully as a learning tool with its annual update and addition of interactive case and quiz modules. To extend web-based learning as an educational tool, we developed a multimedia web-based module for emergency medicine, with video and audio enhancements to simulate patient encounters in the emergency ward setting. Central to the web-module development is the creation of a relational database. We use FileMaker Pro with search, storage, retrieval, image, video and audio incorporation functions, and a built-in interface that allows display of database contents in web templates. Initially the patient's history and presentation are presented with a 30–60 second video followed by key physical findings. The diagnostic studies and management of the patient are then available through sequential interactive quizzes and feedback replies, presented in audio-, video- and image-oriented formats. The format of the quizzes themselves simulates medical board questions. Initial feedback has been favorable. The majority of emergency medicine personnel feel that this module complements and enhances regular lecture sessions. In addition, it enables preservation of interesting and/or infrequently encountered cases for viewing by all residents in Emergency Medicine.     

Use of Standardized Patients in,Undergraduate Medical Genetics Education

Background and Purpose: To study the effectiveness of a standardized patient (SP) program in increasing the competence of medical students in assessing genetic risks and communicating genetic information to patients. Methods: Third-year medical students at the Mount Sinai School of Medicine had two encounters from 2001 to 2003 with the same SP, who portrayed a woman at risk for hereditary breast cancer. Assessment instruments included student self-assessment of skills, SP assessment of student communication skills, an observer checklist, grading of the student-drawn pedigree, and a knowledge test. Students also completed an evaluation form after the debriefing session at the end of each of the SP sessions. Results: The SP program was completed by 136 students. The student self-evaluation of skills instrument revealed that students who completed the SP program felt more competent in their ability to draw a pedigree, assess genetic risks based on family history and pedigree information, and communicate genetic risks compared to students at the same level of training who did not participate in the SP program. Of participating students, 90% agreed that the program allowed them to identify areas for improvement in their skills, and 95% agreed that the exercise increased their confidence for having a similar patient interaction in the future. Conclusions: The use of SPs in undergraduate medical genetics education may be one means for increasing the confidence of medical students in skills that are related to genetic encounters.     

Evidence based practice,and the spirit of inquiry: The Asian example

Evidence based practice (EBP) does not go unnoticed in the healthcare setting in the 21st century. The valued presence of EBP is recognized by the healthcare professionals, educators, health policy makers, private and public payer systems as well as well-informed patients and their families. However, it is not always easy to grasp how well EBP is integrated into the neonatal nurses' daily practices or how well it is understood in concrete terms by the neonatal nursing work force. In this article, the author attempts to provide relevance of foundational concept of EBP to the daily routine seen in the common neonatal intensive care unit (NICU) setting and invites the readers to welcome the concept of EBP as a friendly presence and begin the process by developing the “spirit of inquiry”. Two recent situations are described as examples of how valuable nurses' inquiries are to the vulnerable infants in the NICU setting. The “spirit of inquiry” found among the nurses in Japan and South Korea are likely to be very similar to the inquiry found in the readers' unit in the western world.     

The Emergency Physician and Knowledge Transfer: Continuing Medical Education, Continuing Professional Development, and Self-improvement

A workshop session from the 2007 Academic Emergency Medicine Consensus Conference, Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake, focused on developing a research agenda for continuing medical education (CME) in knowledge transfer. Based on quasi-Delphi methodology at the conference session, and subsequent electronic discussion and refinement, the following recommendations are made: 1) Adaptable tools should be developed, validated, and psychometrically tested for needs assessment. 2) "Point of care" learning within a clinical context should be evaluated as a tool for practice changes and improved knowledge transfer. 3) The addition of a CME component to technological platforms, such as search engines and databases, simulation technology, and clinical decision-support systems, may help knowledge transfer for clinicians or increase utilization of these tools and should, therefore, be evaluated. 4) Further research should focus on identifying the appropriate outcomes for physician CME. Emergency medicine researchers should transition from previous media-comparison research agendas to a more rigorous qualitative focus that takes into account needs assessment, instructional design, implementation, provider change, and care change. 5) In the setting of continued physician learning, barriers to the subsequent implementation of knowledge transfer and behavioral changes of physicians should be elicited through research.     

三级甲等医院内科住院医师层配置和工作负担状况研究

目的调查某三级甲等医院内科各亚专科住院医师层配置和工作负担的现状与问题。方法调查医院内科各专科医师层配置与工作负担，并与卫生部属综合医院医师工作负担及《专科医师培训标准》比较，评价其住院医师层配置和工作负担现状。结果该院除血液科外，住院医师层（含规范化培训住院医师、进修医师和研究生）约占总医师人数的40％～70％；而在编医师仅占20％～50％。若仅考虑医院在编医师人数，则每名在编医师承担的床位数为5．33～15．53张。若仅考虑住院医师层，则每名医师负担的床位数为1．67～9．43张，人均每日担负住院床日为1．27～5．65日，人均每月管理病人数为5．75～17．29例。若考虑各科在编医师和住院医师层人员，各科医师人均负担床位数为1．32～5．87张，人均每日担负住院床日为1～3．63日，人均每月管理病人数为4．18～10．7例。与卫生部各专科培训病例数标准要求和较高要求比较显示：该院肾脏、呼吸、消化、神经内科和传染及感染科住院医师层人均每月管理的病例数超过培养标准的要求，内分泌科低于培养标准要求。结论该院内科各亚专科住院医师层人员配置相对稳定，但流动性大；医师人数不足，总体工作负担较重；各科住院医师层人均管理病例数多数超过卫生部专科医师培养标准要求，且科室差异明显。因此各专科住院医师层应根据工作负担需求合理配置。     

Using an Expanded Outcomes Framework and Continuing Education Evidence to Improve Facilitation of Patient-Centered Medical Home Recognition and Transformation

Background: The patient-centered medical home is a model for delivering primary care in the United States. Primary care clinicians and their staffs require assistance in understanding the innovation and in applying it to practice. Purposes: The purpose of this article is to describe and to critique a continuing education program that is relevant to, and will become more common in, primary care. Methods: A multifaceted educational strategy prepared 20 primary care private practices to achieve National Committee for Quality Assurance Level 3 recognition as Patient-Centered Medical Homes. Results: Eighteen (90%) practices submitted an application to the National Committee for Quality Assurance. On the first submission attempt, 13 of 18 (72%) achieved Level 3 recognition and 5 (28%) achieved Level 1 recognition. Conclusion: An interactive multifaceted educational strategy can be successful in preparing primary care practices for Patient-Centered Medical Homes recognition, but the strategy may not ensure transformation. Future educational activities should consider an expanded outcomes framework and the evidence of effective continuing education to be more successful with recognition and transformation.     

Evaluation of an Online Education Resource on Radiation Therapy Created for Patients with Postprostatectomy Prostate Cancer and Their Caregivers

IntroductionRadiation therapy (RT) after prostatectomy is an important curative treatment option for patients with prostate cancer. It can be delivered immediately after surgery as adjuvant treatment, or after biochemical PSA failure as salvage treatment. There is currently a lack of consensus regarding whether salvage RT in the event of biochemical failure or immediate adjuvant RT is the optimal postprostatectomy RT treatment. Although both types of postprostatectomy RT are generally well tolerated, patients may develop some toxicity that can impact their quality of life and the duration and frequency of treatments can be challenging for patients. It is imperative that patients be provided with evidence-based information so that they are able to make a treatment decision most aligned with their values.MethodsTo help address patients' informational needs, an online education resource was created for patients with prostate cancer considering postoperative RT. Patients and their families were asked to evaluate the effectiveness of this resource using a validated purpose-based information assessment.ResultsNineteen patients were approached and 14 participated, but only five patients returned their evaluations (35%). Sixty percent found the information to be important with regards to each of the six commonly identified purposes in the purpose-based information assessment: organizing, understanding, decision-making, planning, emotional support, and discussing. Only one participant found the information hard to understand and had difficulty finding specific information.DiscussionPatients should be encouraged to actively participate in their treatment decision-making process involving postprostatectomy RT. For patients to make well-informed decisions, patients must be provided with clear and accessible information so that they may understand their disease and the treatment options.ConclusionAn online education resource has been developed that most study respondents found clear and helpful for a variety of identified purposes. Overall, this online education resource has the potential to reach a large number of patients and their caregivers who desire specific information and involvement in future treatment decisions.