Do clerkship directors think medical students are prepared for the clerkship years?

PURPOSE: Educators have begun to question whether medical students are adequately prepared for the core clerkships. Inadequate preclerkship preparation may hinder learning and may be predictive of future achievement. This study assessed and compared the views of clerkship directors regarding student preparation for the core clinical clerkships in six key competencies. METHOD: In 2002, a national survey was conducted of 190 clerkship directors in internal medicine, family medicine, pediatrics, surgery, obstetrics/gynecology, and psychiatry from 32 U.S. medical schools. Clerkship directors were asked to report their views on the appropriate level of student preparation needed to begin the core clinical clerkships (none, minimal, intermediate, advanced), and the adequacy of that preparation (ranging from "much less" to "much more than necessary") in six key clinical competencies. RESULTS: A total of 140 clerkship directors responded (74%). The majority reported that students need at least intermediate ability in five of six competencies: communication (96%), professionalism (96%), interviewing/physical examination (78%), life-cycle stages (57%), epidemiology/probabilistic thinking (56%), and systems of care (27%). Thirty to fifty percent of clerkship directors felt students are less prepared than necessary in the six competencies. Views were similar across all specialties and generally did not differ by other clerkship director characteristics. CONCLUSIONS: Almost half of clerkship directors were concerned that students do not receive adequate preparation in key competencies before starting the core clinical clerkships. Many medical schools may need to give more attention to the preclerkship preparation of students in these high-priority areas.     

Developing interventions for chronically ill patients: is coping a helpful concept?

In this review, the role of coping in the development of psychosocial interventions for chronically ill patients is discussed. After summarizing the theoretical issues involved in the translation of the coping concept into an intervention, a review is undertaken of 35 studies concerned with the impact of interventions aimed at improving coping on patients' quality of life. These studies concern seven different chronic disease types (AIDS, asthma, cancer, cardiovascular diseases, chronic pain, diabetes, and rheumatoid arthritis) and show explicit consideration of attempts to manage illness in terms of coping to be rare. Many studies nevertheless address the equivalent of coping, namely behaviors and/or cognitions intended to deal with an illness situation appraised as stressful. The results of these studies are encouraging, although largely limited to the improvement of one or two particular coping strategies and problem-focused strategies in particular. It is argued that in order to expand on these initially positive findings, greater and more explicit consideration should be given to the potential of the coping concept for intervention with the chronically ill. The appraisal of stressful situations, the use of coping resources, and the strategic application of particular coping strategies should, for example, be given more careful consideration.     

Can the common-sense model predict adherence in chronically ill patients? A meta-analysis

Health-related interventions often prompt participants to plan how to cope with anticipated barriers to behaviour change, a technique known as coping planning. The purpose of this study was to review the evidence of the efficacy of prompting individuals to form coping plans as a technique for promoting health-related behaviour change. Electronic databases (MEDLINE, Embase and PsycInfo) and unpublished literature were searched for randomised controlled trials that allocated participants to the study conditions with and without prompts to form coping plans. Evidence was assessed for quality and narratively synthesised. Full text papers of 65 articles were assessed for eligibility and 11 papers were included in the review. Coping planning interventions appear to be efficacious when participants are supported in the process of forming coping plans. Combining action plans with coping plans seems to be more efficacious than using action plans only. The overall efficacy of coping planning is variable. Future interventions should consider potential moderators of the efficacy of such plans.     

Preferences and experiences of chronically ill and disabled patients regarding shared decision-making: Does the type of care to be decided upon matter?

Objective

(1) To describe the importance chronically ill and disabled patients attach to involvement in decision-making when various care types are considered, and (2) to analyse the degree to which these patients are involved in shared decision-making (SDM) regarding these care types, and whether their involvement reflects the importance they attach to SDM.

Methods

The study sample consisted of 812 chronically ill and disabled patients who experienced a situation of decision-making during the last year. Data were collected by a self-report survey in 2006 and were analysed by multilevel linear regression analyses.

Results

Participants attached most importance to SDM when occupational healthcare issues were at stake, but perceived their actual involvement in these decisions as relatively low. Patients dealing with decision-making regarding medical care or home care experienced higher levels of involvement. The importance attached to SDM corresponds moderately with the actual role patients experience in the decision-making process.

Conclusion

The type of care to decide upon impacts on the importance patients attach to SDM as well as on their actual involvement in decision-making.

Practice implications

We suggest healthcare practitioners to pay attention to the preferred level of patient involvement each time a new care issue has to be decided upon.     

How do patients value and prioritize patient portal functionalities and usage factors? A conjoint analysis study with chronically ill patients

Background

Patient portal use can be a stimulant for patient engagement. Yet, the heterogeneous landscape of tethered patient portals, is a major barrier to further portal development and implementation. A variety in portal access means, functionalities, usability and usefulness exists; without having accurate sight on patient perspectives. We aimed to get insights on possible coherence between patients’ preferred usage factors of portals and patients’ prioritization of functionalities, within the complexity of their disease management across different healthcare organizations.

Methods

A conjoint analysis questionnaire was sent to patient panels of two large patient associations in The Netherlands, centered on heart and vascular diseases and lung diseases.

Results

Of 1294 patient respondents, 81% were 55+ years old and 49% were 65+ years old. Overall respondents significantly prioritized user-friendly access to a portal, via a laptop or desktop. Patients aged <?65 were less negative about using tablets to access a portal compared to the total respondents. Patients had no preference for a digital interoperable export functionality; most respondents preferred to create printable overviews. Built-in publication delay of two weeks for medical information was not preferred. Our results show no significant preference of patients between ‘instant publication’ versus ‘publication after new information has been explained by a healthcare provider’. Overall respondents and experienced portal users had a strong preference to be able to communicate with their provider via a portal and to use a portal providing information from multiple providers. Lung patients preferred information from one provider and did not require the possibility to ask online questions.

Conclusions

Heart and vascular patients as well as lung patients prefer similar technical patient portal aspects, independent of their medical condition. Yet, in current portals consistency on this matter is lacking. It is highly assumable that offering a more consistent user-experience across the variety of patient portals could help increase patient portal acceptance, ultimately helping to stimulate patient engagement via patient portal use. We further affirm the need for customization on medical information publication and sharing information of various providers through patient portals, where information provision can be adapted to preferences of patients related to their medical condition(s).

     

Are spouses of chronically ill partners burdened by exerting health-related social control?

Spouses often seek to influence the health behaviors of chronically ill partners, but little research has examined whether spouses find such involvement to be burdensome. The current study examined this question in a sample of 191 nondiabetic spouses whose partners had type 2 diabetes. Results revealed that spouses who attempted to exert more control over their partners' dietary behavior experienced greater burden, particularly when their partners exhibited poor dietary adherence and reacted negatively to spouses' involvement. The findings contribute to a sparse body of knowledge on how spouses are affected by efforts to influence their chronically ill partners' disease management.     

Do implicit attitudes toward physical activity and sedentary behavior prospectively predict objective physical activity among persons with obesity?

This study conducted among adults with obesity examined the associations between implicit attitudes toward physical activity and sedentary behavior, and physical activity behavior measured 4 months later. At baseline, 76 participants (M _AGE = 56; M _BMI = 39.1) completed a questionnaire assessing intentions toward physical activity and sedentary behavior and two computerized Single-Category Implicit Association Tests assessing implicit attitudes toward these two behaviors. At follow-up, physical activity was measured with accelerometers. Multiple regression analysis showed that implicit attitudes toward physical activity were positively and significantly associated with physical activity when participants’ age, BMI, past physical activity and intentions were controlled for. Implicit attitudes toward sedentary behavior were not associated with physical activity. Adults with obesity who implicitly reported more favorable attitudes toward physical activity at baseline were more likely to present higher physical activity levels at follow-up. Implicit attitudes could be targeted in future research to enhance physical activity.     

Do NSAIDs affect the progression of osteoarthritis?

NSAIDs are widely used to alleviate the symptoms of OA. It remains controversial as to what effects these agents have on the progression of OA. In vitro studies showed several types of NSAIDs (e.g., sodium salicylate, indomethacin) inhibited the synthesis of cartilage matrix component, but some types of NSAIDs (e.g., aceclofenac, meloxicam, nimesulide) increased the matrix component synthesis and protected the chondrocytes against apoptosis, while others (e.g., piroxicam) had no effects. Studies in animal models verified that NSAIDs had favourable or detrimental action on OA progression, even the same NSAID (e.g., naproxen, tiaprofenic acid) had reverse effects on articular cartilage in different studies. Preliminary clinical trials revealed some NSAIDs such as indomethacin had a negative influence on joint structure, other NSAIDs such as diclofenac and naproxen had no acceleration of radiographic damage to OA within 2-years of treatment. So far, there are no convincing data to show the widely used NSAIDs and recommended selective COX-2 inhibitor have favourable effects on cartilage. Therefore, it is necessary and valuable to clarify the effects of these NSAIDs on cartilage in patients with OA using validated non-invasive methods such as MRI.     

Do high-flux dialysis membranes affect renal dyslipidemia?

High-flux hemodialysis has been reported to attenuate renal dyslipidemia. To evaluate the contribution of dialysis membrane composition per se, we compared the impact on the lipoprotein profile of hemodialysis (HD) with a conventional cellulose dialysis membrane with that of a synthetic high-flux dialysis membrane in standard hemodialysis mode. Forty-two patients (24 men, 18 women; mean age, 69 years; range, 39-85 years) on maintenance HD with cellulosic dialysis membranes were randomized and stratified for diabetes mellitus to 12 weeks of HD treatment with either a cellulose acetate (CA; n = 23) or polyacrylonitrile (AN69; n = 19) membrane. HD was performed in a conventional low-flux standard HD mode 4-6 hours/session. Plasma levels of lipids (TC, TG), apolipoproteins (A-I, B, C-III, E), lipoprotein (a) (Ip(a)), and individual apoA and apoB containing lipoproteins (LP-A-I, LP-A-I:A-II, LP-B, LP-Bc) were determined. At baseline, the AN69 group had slightly higher plasma concentrations of apoC-III and C-III/HS, but there were no other differences at entry in study variables between the treatment groups. Twelve week treatment with an AN69 membrane did not result in any significant changes in lipoprotein profile compared with treatment with a cellulose acetate membrane. HD with AN69 dialysis membranes in the conventional low-flux standard hemodialysis mode does not affect the lipoprotein profile.     

Why do patients engage in medical tourism?

Medical tourism is commonly perceived and popularly depicted as an economic issue, both at the system and individual levels. The decision to engage in medical tourism, however, is more complex, driven by patients’ unmet need, the nature of services sought and the manner by which treatment is accessed. In order to beneficially employ the opportunities medical tourism offers, and address and contain possible threats and harms, an informed decision is crucial. This paper aims to enhance the current knowledge on medical tourism by isolating the focal content of the decisions that patients make. Based on the existing literature, it proposes a sequential decision-making process in opting for or against medical care abroad, and engaging in medical tourism, including considerations of the required treatments, location of treatment, and quality and safety issues attendant to seeking care. Accordingly, it comments on the imperative of access to health information and the current regulatory environment which impact on this increasingly popular and complex form of accessing and providing medical care.     

Why do patients engage in medical tourism?

Medical tourism is commonly perceived and popularly depicted as an economic issue, both at the system and individual levels. The decision to engage in medical tourism, however, is more complex, driven by patients’ unmet need, the nature of services sought and the manner by which treatment is accessed. In order to beneficially employ the opportunities medical tourism offers, and address and contain possible threats and harms, an informed decision is crucial. This paper aims to enhance the current knowledge on medical tourism by isolating the focal content of the decisions that patients make. Based on the existing literature, it proposes a sequential decision-making process in opting for or against medical care abroad, and engaging in medical tourism, including considerations of the required treatments, location of treatment, and quality and safety issues attendant to seeking care. Accordingly, it comments on the imperative of access to health information and the current regulatory environment which impact on this increasingly popular and complex form of accessing and providing medical care.     

Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?

Context:

Hospital-acquired hypernatremia (HAH) is a frequent concern in critical care, which carries high mortality.

Aims:

To study the risk factors for HAH in settings that practice a preventive protocol.

Settings and Design:

Two tertiary-care hospitals. Prospective observational study design.

Materials and Methods:

Patients aged >18 years admitted for an acute medical illness with normal serum sodium and need for intensive care >48 h formed the study population. Details of the basic panel of investigations on admission, daily electrolytes and renal function test, sodium content of all intake, free water intake (oral, enteral and intravenous) and fluid balance every 24 h were recorded. Individuals with serum Na 140-142 meq/l received 500 ml of free water every 24 h, and those with 143-145 meq/l received 1000 ml free water every 24 h.

Statistical Analysis Used:

Risk factors associated with HAH was analysed by multiple logistic regression.

Results:

Among 670 study participants, 64 (9.5%) developed HAH. The median duration of hypernatremia was 3 days. A total 60 of 64 participants with HAH had features of renal concentrating defect during hypernatremia. Age >60 years (P = 0.02), acute kidney injury (AKI) on admission (P = 0.01), mechanical ventilation (P = 0.01), need for ionotropes (P = 0.03), worsening Sequential Organ Failure Assessment (SOFA) score after admission (P < 0.001), enteral tube feeds (P = 0.002), negative fluid balance (P = 0.02) and mannitol use (P < 0.001) were the risk factors for HAH. Mortality rate was 34.3% among hypernatremic patients.

Conclusions:

The study suggests that administration of free water to prevent HAH should be more meticulously complied with in patients who are elderly, present with AKI, suffer multi-organ dysfunction, require mechanical ventilation, receive enteral feeds and drugs like mannitol or ionotropes.     

CMV in critically ill patients: pathogen or bystander?

Despite broad variability in study populations, methodologies for CMV detection, and analytic methods used, multiple studies have documented frequent CMV infection in non-immunocompromised adults with critical illness due to a variety of causes. Higher rates of CMV infection in studies of seropositive patients suggest that reactivation of latent infection rather than primary infection is the main mechanism in this setting. Risk factors for CMV reactivation (other than seropositivity) have not been clearly defined and there does not appear to be a consistent association with severity of illness. Furthermore, CMV reactivation in this setting has been associated with important adverse clinical outcomes, including increased duration of mechanical ventilation, longer length of stay and all-cause mortality. There are several biologically plausible mechanisms that could link CMV reactivation with adverse outcomes, including: direct lung injury (CMV pneumonia), amplification of inflammation systemically and within the lung, or predisposition to other nosocomial infections, but clinical data in the ICU setting are limited. Further observational studies are unlikely to significantly advance our understanding of the role of CMV in critically ill patients. Given the significant impact of critical illness, limited current therapeutic options, the availability of generally well-tolerated antiviral options for CMV, and the clinical data supporting a possible pathogenic role for CMV, there is a strong rationale for a randomised controlled trial of CMV prevention as a novel means of improving the outcomes of critically ill patients.     

Do citizens have minimum medical knowledge? A survey

Background

Experts defined a "minimum medical knowledge" (MMK) that people need for understanding typical signs and/or risk factors of four relevant clinical conditions: myocardial infarction, stroke, chronic obstructive pulmonary disease and HIV/AIDS. We tested to what degree Swiss adult citizens satisfy this criterion for MMK and whether people with medical experience have acquired better knowledge than those without.

Methods

Questionnaire interview in a Swiss urban area with 185 Swiss citizens (median age 29 years, interquartile range 23 to 49, 52% male). We obtained context information on age, gender, highest educational level, (para)medical background and specific health experience with one of the conditions in the social surrounding. We calculated the proportion of MMK and examined whether citizens with medical background (personal or professional) would perform better compared to other groups.

Results

No single citizen reached the full MMK (100%). The mean MMK was as low as 32% and the range was 0 -72%. Surprisingly, multivariable analysis showed that participants with a university degree (n = 84; β (95% CI) +3.7% MMK (0.4–7.1) p = 0.03), (para)medical background (n = 34; +6.2% MMK (2.0–10.4), p = 0.004) and personal illness experience (n = 96; +4.9% MMK (1.5–8.2), p = 0.004) had only a moderately higher MMK than those without, while age and sex had no effect on the level of MMK. Interaction between university degree and clinical experience (personal or professional) showed no effect suggesting that higher education lacks synergistic effect.

Conclusion

This sample of Swiss citizens did not know more than a third of the MMK. We found little difference within groups with medical experience (personal or professional), suggesting that there is a consistent and dramatic lack of knowledge in the general public about the typical signs and risk factors of relevant clinical conditions.     

Children's attitudes and behavioral intentions toward a peer presented as obese: does a medical explanation for the obesity make a difference?

OBJECTIVE: To examine the effect of information on children's attitudes and behavioral intentions toward a peer presented as obese. METHODS: Children (N = 184) were randomly assigned to observe a video of a boy or girl in one of three conditions: average-weight, obese, obese with medical information explaining the obesity. They rated stereotypical attitudes on the Adjective Checklist and behavioral intentions on the Shared Activities Questionnaire (SAQ-B). RESULTS: Ratings were generally more favorable for the average-weight than for the obese condition. However, provision of medical information had a positive effect on attitudes toward the obese peer only for younger children and a negative effect on willingness of older children to share academic activities with the peer. Boys and girls showed more positive behavioral intentions toward the same-sex target child regardless of obesity condition. CONCLUSIONS: Information explaining obesity has a minimal positive effect on children's attitudes and behavioral intentions toward a peer presented as obese.     

Does General surgery clerkship make a future career in surgery more appealing to medical students?

Background

Medical students'' decreasing interest in surgical careers has raised much concern. This report is to ascertain the influence of surgical clerkship on the perceptions of medical students on prospects of a future career interest in surgery.

Methods

A cross sectional study, involving final year medical students. Information concerning their interest in a surgical career, what they thought of surgery before and after general surgery clerkship was obtained.

Results

A total of 120 medical students participated in the study. The age range was 24 – 36 years (mean 27+2). There were 87 (72.5%) males and 33(27.5%) females.Ten students (8.0%) were interested in surgery before their last surgery clerkship, 18 (15%) Obstetric and Gynaecology, 92(76.6%) others. Those that developed interest in surgery following the clerkship increased to 33 (27.5%) (P<0.001), 34 (28.3%) Obstetric & Gynecology, while other specialties reduced to 53 (44.2%).One hundred and one (84.2%) (M=71, F=30) students believe they had identified a role model or a mentor during the clerkship, either a consultant or a resident. Eighty eight (73.3%) (M=62, F=26) student who liked and loved surgery at the end of the clerkship identified surgical mentors during their time.

Conclusion

General surgical clerkship has influence on future career in surgery among medical students. Focused and effective mentoring by faculty as well as early exposure of students to positive role models should help to reverse negative impressions held by students.     

A longitudinal study of third-year medical students’ communication competence,communication anxiety,and attitudes toward patient-centered care

ObjectiveWe investigated changes in medical students’ communication competence and communication anxiety during their third year of training when they are immersed in formative clinical experiences that shape their patient-centered care and communication skills.MethodsWe invited 282 students to complete a longitudinal, four-phase online survey during their third-year. Our response rate was 62.8% at Phase I (n = 177), 34.0% at Phase II (n = 96), 37.9% at Phase III (n = 107), and 48.9% at Phase IV (n = 138). Measures included communication competence, communication anxiety, and patient-centered attitudes and orientation. We employed hierarchical linear modeling to analyze the data.ResultsStudents’ communication competence and anxiety improved over time. Female students reported greater communication anxiety and less competence related to information giving. At each phase, patient-centered attitudes significantly predicted communication competence and communication anxiety.ConclusionStudents’ competence and anxiety regarding communication during medical encounters improve during their third year and are significantly influenced by their attitudes and orientation towards patient-centered care and communication.Practice implicationsSchools should integrate curriculum that fosters positive attitudes toward patient-centered communication and provides opportunities to practice complex communication skills, which may increase competence and recognition that patient-centered communication is an important clinical skill.     

Longitudinal study: Impact of communication skills training and a traineeship on medical students’ attitudes toward communication skills

ObjectivesTo study longitudinally students’ attitudes towards communication skills (CS) in order to examine whether CS training (CST) has an enduring impact on medical students’ attitudes toward being a lifelong learner of CS.Methods105 students completed the Communication Skills Attitude Scale at 4 times: before CST, after CST and before and after a traineeship.ResultsOur final sample size is 105 students. CST improved the attitudes of our students toward CS, and the traineeship stabilised those attitudes. However, while the improvement in positive attitudes was sustained over time, negative attitudes increased 6 months after CST.ConclusionCST using experiential methods in a safe environment has the potential to improve students’ attitudes towards CS. A short traineeship in general medicine allows students to quickly integrate CST into clinical practice, without deteriorating their attitudes toward CS. However, 6 months of medical lessons without CST reinforces students’ negative attitudes.Practice implicationsTo avoid the deterioration of attitudes over time, CST should be continuous or at least spaced at intervals less than 6 months and supported by the institutional authorities. In addition, placing the CST close to an observation traineeship in general practice seems an interesting way to prevent further deterioration of attitudes.