The rheumatology knowledge and skills of trainees in internal medicine and family practice

Our study examines the rheumatology knowledge and skills of trainees in internal medicine and family practice residency programs. Site visits were made to 15 programs in the eastern half of the United States. Eighty-one trainees participated in the study, 53 in internal medicine and 28 in family practice. Each completed a 50-item rheumatology quiz and performed a clinical assessment of a trained patient evaluator. Trainees in internal medicine had quiz and clinical assessment scores of 52.4% and 72.9%, respectively, while scores for family practice trainees were 43.4% and 61.6% (p less than 0.004 for both). Regression analysis showed that having had a rheumatology elective had a significant effect on knowledge and skills. Trainees in family practice programs were 3 times less likely than internal medicine trainees to have taken a rheumatology elective. Family practice trainee scores in our study were comparable to scores previously documented in 4th year medical students. These results confirm the importance of a specific rheumatology experience for the development of rheumatology knowledge and skills in internal medicine and family practice trainees, and suggest that the rheumatology content of these training programs needs to be enhanced.     

Virtual reality and written assessments are of potential value to determine knowledge and skill in flexible bronchoscopy

BACKGROUND: Technically challenging professions such as those of the defense and transportation industries increasingly use computer-based simulation and written self-learning instruments for education and to determine competency. A structured learning curriculum does not exist, however, for flexible bronchoscopy, a minimally invasive diagnostic procedure performed on thousands of patients by respiratory specialists, otolaryngologists, anesthesiologists, and surgeons worldwide. OBJECTIVE: To explore an analogous strategy of measuring theoretical knowledge in flexible bronchoscopy and specific technical skills using written knowledge assessments and a virtual reality bronchoscopy simulator. METHODS: Twelve trainees from a university pulmonary medicine training program were asked to identify and enter five specific bronchial segments on command using a virtual reality bronchoscopy skill station, and to complete a 50-question examination pertaining to bronchoscopy theory. Their performance scores and opinions pertaining to the use of these methods of assessment were then recorded. RESULTS: Trainees correctly identified and entered 71% of the bronchial segments required on command (median 60%, range 40-100%). Fifty percent (3/6) of the trainees who had performed more than 200 flexible bronchoscopies successfully entered all segments required. None (0/6) of those who had performed less than 200 flexible bronchoscopies correctly located, identified and entered all required segments. Despite disparate performance, all trainees believed that technical skills could be improved through practice and instruction using computer-based simulation. On the written assessment, only 51% of questions were answered correctly (median 52%, range 32-60%). No relationship between technical skill and theoretical knowledge was noted. In addition, neither bronchoscopy skill nor theoretical knowledge were associated with years of training or number of bronchoscopies previously performed. CONCLUSIONS: Trainees concluded that (1) bronchoscopy simulation was realistic, (2) simulator-based practice would help improve technical skills, and (3) a written questionnaire would benefit theoretical knowledge acquisition if designed as a learning instrument. The wide variability noted in this study as well as the lack of a relationship between technical skill, knowledge of bronchoscopy theory, extent of training, and bronchoscopy experience suggest that competency should not be assumed based on years of bronchoscopy training or on an arbitrary number of procedures performed.     

Simulation-based mastery learning in gastrointestinal endoscopy training

Simulation-based mastery learning (SBML) is an emerging form of competency-based training that has been proposed as the next standard method for procedural task training, including that in gastrointestinal endoscopy. Current basic gastrointestinal endoscopy training relies on the number of procedures performed, and it has been criticized for its lack of objective standards that result in variable skills among trainees and its association with patient safety risk. Thus, incorporating simulators into a competency-based curriculum seems ideal for gastrointestinal endoscopy training. The curriculum for SBML in gastrointestinal endoscopy is currently being developed and has promising potential to translate into the clinical performance. Unlike the present apprenticeship model of “see one, do one, teach one,” SBML integrates a competency-based curriculum with specific learning objectives alongside simulation-based training. This allows trainees to practice essential skills repeatedly, receive feedback from experts, and gradually develop their abilities to achieve mastery. Moreover, trainees and trainers need to understand the learning targets of the program so that trainees can focus their learning on the necessary skills and trainers can provide structured feedback based on the expected outcomes. In addition to learning targets, an assessment plan is essential to provide trainees with future directions for their improvement and ensure patient safety by issuing a passing standard. Finally, the SBML program should be planned and managed by a specific team and conducted within a developed and tested curriculum. This review discusses the current state of gastrointestinal endoscopy training and the role of SBML in that field.     

Chief resident immersion training in the care of older adults: an innovative interspecialty education and leadership intervention

Chief residents (CRs) play a crucial role in training residents and students but may have limited geriatrics training or formal preparation for their CR role. A 2-day off-site chief resident immersion training (CRIT) addressed these challenges. Objectives were to foster collaboration between disciplines in the management of complex older patients, increase knowledge of geriatrics principles to incorporate into teaching, enhance leadership skills, and help CRs develop an achievable project for implementation in their CR year. Three cohorts totaling 47 trainees and 18 faculty mentors from 13 medical and surgical disciplines participated over 3 successive years. The curriculum, developed and taught by a multidisciplinary team, featured an interactive surgical case, mini-lectures on geriatrics topics, seminars to enhance teaching and leadership skills, and one-on-one mentoring to develop a project in geriatric care or education. Evaluation included pre- and postprogram tests and self-report surveys and two follow-up surveys or interviews. In 2006 and 2007, scores on a 12-item objective knowledge test increased significantly ( P <.001) from before to immediately after CRIT. Self-report knowledge and confidence in teaching geriatrics also increased significantly ( P <.05) in all formally covered topics. Mean enhancement of CR skills was 4.3 (1=not at all, 5=very much). Eleven months after CRIT, all but five CRs had implemented at least part of their action projects. CRs reported improved care of older patients, better leadership skills, more and better geriatrics teaching, and more collaboration between disciplines. A 2-day interactive program for CRs can increase institutional capacity regarding geriatrics teaching and care of elderly patients across medical specialties.     

Do Internists,Pediatricians, and Psychiatrists Feel Competent in Obesity Care?

BACKGROUND  Physicians must effectively evaluate and treat obesity. To design a needs-driven curriculum intended to improve patient outcomes, physicians were surveyed about their self-perceived knowledge and skills. OBJECTIVE  The objective of this study was to determine the expressed needs of residents and faculty regarding obesity care training across three specialties. DESIGN  The study used a survey given to faculty and residents in General Internal Medicine, Pediatrics, and Psychiatry. METHODS  Survey questions were generated from comprehensive nutrition curriculum and clinical recommendations, administered online, and then organized around a validated behavioral health framework—the 5As (assess, advise, agree, assist, arrange). Analyses were conducted to evaluate differences in perceived knowledge and skills between specialties and across training levels. RESULTS  From an overall response rate of 65% (65 residents and 250 faculty members), nearly 20% reported inadequate competency in every item with 48% of respondents reporting an inability to adequately counsel patients about common treatment options. Internists reported the lowest competency in arranging referrals and follow-up. Psychiatrists reported the lowest competency in assessment skills. CONCLUSIONS  This survey demonstrated a critical need for training in specific areas of obesity care. The proposed curriculum targets these areas taking into consideration observed differences across specialties.     

Development and Implementation of a Formalized Geriatric Surgery Curriculum for General Surgery Residents

Despite the growth of the elderly population, most surgical training programs lack formalized geriatric education. The authors’ aim was to implement a formalized geriatric surgery curriculum at an academic medical center. Surgery residents were surveyed on attitudes toward the care of elderly patients and the importance of various geriatric topics to daily practice. A curriculum consisting of 16 didactic sessions was created with faculty experts moderating. After curriculum completion, residents were surveyed to assess curriculum impact. Residents expressed increased comfort in accessing community resources. A greater percentage of residents recognized the significance of delirium and acute renal failure in elderly patients. Implementing a geriatric surgery curriculum geared toward surgery residents is feasible and can increase resident comfort with multidisciplinary care and recognition of clinical conditions pertinent to elderly surgical patients. This initiative also provided valuable experience for geriatric surgery curriculum development.     

The Development and Implementation of a Competency-Based Curriculum for Training in Global Health Research

The Fogarty International Center (FIC) Global Health Fellows Program provides trainees with the opportunity to develop research skills through a mentored research experience, increase their content expertise, and better understand trends in global health research, funding organizations, and pathways to generate support. The Northern Pacific Global Health Fellows Research and Training Consortium, which hosts one of the FIC Global Health Programs, sought to enhance research training by developing, implementing, and evaluating a competency-based curriculum that uses a modular, asynchronous, web-based format. The curriculum has 8 core competencies, 36 learning objectives, and 58 assignments. Nineteen trainees completed their 11-month fellowship, engaged in the curriculum, and provided pre- and post-fellowship self-assessments. Self-assessed scores significantly improved for all competencies. Trainees identified the curriculum as one of the strengths of the program. This competency-based curriculum represents a first step toward creating a framework of global health research competencies on which further efforts could be based.     

Gastroenterology training and career choices: a prospective longitudinal study of the impact of gender and of managed care

OBJECTIVE: We aimed to determine if gender differences exist in the selection and training of female and male gastroenterology fellows. METHODS: One hundred seventy-six of 218 training program directors returned an 18-question survey about their programs, including leave policies, training, and prevalence of female faculty. Two cohorts of graduating trainees from 1993 and 1995 (N = 393) returned anonymous surveys regarding their training program experiences, demographics, and business training. RESULTS: Female gastroenterology trainees are more likely to choose programs according to parental leave policies (p < 0.05), female faculty (0.2990 correlation coefficient), and "family reasons" (p < 0.04) than the male trainees. Female trainees were more likely to remain childless (p < 0.001) or have fewer children at the end of training despite marital status not unlike their male colleagues. Female trainees altered their family planning because of training program restrictions (20% vs 7%, p < 0.001). They perceived gender discrimination (39%) and sexual harassment (19%) during gastroenterology training. Trainees of both sexes had mentorship during training (65% vs 71%, ns); female trainees were more likely to have an opposite sex mentor (71% vs 3.4%) despite an almost 50% prevalence of female full-time and clinical faculty. Female trainees were apt to be less trained in advanced endoscopy (p < 0.005). Trainees of both sexes were influenced by the changing health care environment in career choice (49% vs 42%, ns); neither gender felt adequately prepared for the business aspects of gastroenterology. CONCLUSION: Alterations in gastroenterology training are needed to attract qualified female applicants. New graduates of both sexes lack practice management education.     

心血管内外科住院医师规范化培训学员满意度调查与分析

目的 调查分析遵义医学院附属医院心血管内外科住院医师规范化培训学员对规范化培训的相关方面内容的满意度情况。方法 选取我院2015级规范化培训学员为研究对象，采用现场发放调查问卷方法进行无记名调查分析。问卷调查内容包括:规范化培训的带教内容及教学方法、培训环境及设备安排、主管部门对培训工作的重视程度、住院医师培训与相关信息传达及时性、我院对规范化培训授课工作的重视程度、我院对临床工作能力及相关信息传达及时性、公共科目集中授课和专业课技能训练所安排的比例以及今后在那些方面还需要改进等。并了解学员各个方面的满意度。结果 对于此次问卷调查，发现大多学员还是喜欢这项培训工作的，对于我院老师的带教方法、带教内容、授课内容及其质量及主管部门的重视程度还是比较满意的。结论 大多数学员对我院住院医师规范化培训比较满意，获得学员认可的，可吸引更多学员加入我们的队伍，但是与国外相比，还有很大的差距。我们仍需要继续努力，不断为社会培养优秀医学人才。     

Rheumatology education and management skills in general practice: a national study of trainees.

OBJECTIVE--To evaluate current rheumatology education and skills during vocational training in general practice. METHODS--A postal questionnaire survey was sent to all general practice trainees who were in United Kingdom training practices in June 1992. A second survey was made of general practice trainers in the UK. RESULTS--Questionnaires were returned by 1624 trainees, representing 70% of all trainees known to be in a training practice on 1 April 1992. Of the 1075 responders who were at the end of their trainee year, 35% had not received any tutorials on rheumatological topics with their trainer, and only 43% had experienced specific rheumatology teaching on local day release courses. Although 84% of these trainees had injected or aspirated the knee, fewer than 40% had acquired shoulder injection skills. Lack of experience was matched by low reported confidence. Trainees rated the amount of their rheumatology education as inadequate. Nine hundred trainers returned questionnaires--a response rate of 33%. Their estimate of the amount of local training provided was similar to that among the trainees, but this sample of trainers reported a higher level of practical teaching than the trainees indicated they had received. CONCLUSIONS--Rheumatology education during vocational training needs to be improved, particularly the component provided by trainers and local day release courses. This process might be facilitated by the development of a standard rheumatology curriculum which could be incorporated into all training schemes.     

Advanced heart failure: prognosis, uncertainty, and decision making

Heart failure is a serious clinical management challenge for both patients and primary care physicians. The authors studied the perceptions and practices of internal medicine residents and faculty at an academic medical center in the Southeast to guide design of strategies to improve heart failure care. Data were collected via a self-administered survey. Eighty-nine faculty and resident physicians in general internal medicine and geriatrics participated (74% response rate). Items measured perceived skills and barriers, adherence to guidelines, and physician understanding of patient prognosis. Case studies explored practice approaches. Clinical knowledge and related scales were generally good and comparable between physician groups. Palliative care and prognostic skills were self-rated with wide variance. Physicians rated patient noncompliance and low lifestyle change motivation as major barriers. Given the complexities of caring for elderly persons with heart failure and comorbid conditions, there are significant opportunities for improving physician skills in decision making, patient-centered counseling, and palliative care.     

Are Training Programs Ready for the Rapid Adoption of CCTA?: CBME in CCTA

ObjectivesThis study sought to assess training volumes and its relationship to learning and identify potential new thresholds for determining expertise.BackgroundCompetency-based medical education (CBME) is being rapidly adopted and therefore training programs will need to adapt and identify new and novel methods of defining, measuring, and assessing clinical skills.MethodsConsecutive cardiac computed tomography (CT) studies were interpreted independently by trainees and expert readers, and their interpretations (Agatston score, coronary artery disease severity, and Coronary Artery Disease Reporting and Data System) were collected. Kappa agreements were measured between trainees and experts for every 50 consecutive cases. Agreements between trainees and experts were tracked and compared with the agreement between expert readers.ResultsA total of 36 trainees interpreted 14,432 cardiac CT studies. Agreement between trainees and experts increased with CT case volumes, but trainees learned at different rates. Using a threshold for expertise, skill of measuring coronary calcification was achieved within 50 cases, but expertise for coronary CT angiography appeared to require a mean case volume of 750, comprising 400 abnormal cases.ConclusionsCurrent volume-based training guidelines may be insufficient and higher case volumes may be required. We demonstrate that tracking cardiac CT learners is feasible and that CBME could be incorporated into CT training programs.     

Family Medicine and Primary Care Internal Medicine Residents' Attitudes Toward Care of the Elderly

Family medicine and primary care internal medicine residents in a university training program were surveyed about their attitudes toward caring for the elderly. Respondents reported satisfaction with care of the elderly. They considered caring for elderly patients to be medically challenging and reported that they learned an appreciable amount of medicine from elderly patients. The residents were less positive about their impact on elderly patients' health and the quality of care they delivered. Rather than supporting the belief that residents have negative attitudes toward the elderly, the study suggests this group of residents has positive attitudes about caring for this population. Their more negative responses about caring for this population. Their more negative responses about the quality of care they deliver suggest they would be receptive to learning more about delivery of health care to the elderly.     

Doctoral Clinical Geropsychology Training in a Primary Care Setting

Abstract

Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica, to clinical psychology doctoral students within a large urban professional psychology program. In an innovative effort to provide the most disadvantaged elderly with comprehensive mental health treatment and maximize trainee exposure to an interdisciplinary treatment model, the program also pairs selected doctoral psychology trainees with medical residents to optimize integrated mental health service delivery for primary care elderly. The program has the following core objectives: (1) Infuse the mental health and aging knowledge base into the regular graduate curriculum; (2) Provide interdisciplinary training in geropsychological diagnostic and consultative services within an urban primary care setting; (3) Provide interdisciplinary training in the practice of psychological and neuropsychological evaluation of elderly; (4) Provide training in geropsychological psychotherapeutic intervention, including individual, couples/family, and brief/psycho-educational therapies with outpatient older adults. These objectives are achieved by pooling the resources of a graduate school of psychology, a local public hospital, and an academic medical center to achieve educational and clinical service goals.     

Colorectal operative experience in general surgical training

Background: Surgical trainees often feel that their operative training is inadequate – trainers usually do not share this view. Methods: The distribution of colorectal operative surgical workloads between consultants and trainees was examined over a 15-year period in the Colorectal Service at the Wellington School of Medicine. Results: Consultants performed 947 operations and trainees performed 1012 operations. The average age of patients operated on by trainees was lower than that of those operated on by consultants. Trainees performed more emergency surgery. Anorectal surgery, except fistula surgery, was more commonly performed by trainees, whereas abdominal colorectal surgery was more commonly performed by consultants. Trainees had lower postoperative morbidity and mortality rates. The diseases predominantly treated by consultants and trainees differed. Twenty-four percent of patients with colorectal cancers and 25% of patients with diverticular disease were managed operatively by trainees. Yearly trainee workloads for minor anorectal conditions were similar to those of trainees in the USA. Conclusion: Although this small colorectal audit provides some information about trainees' operative experience, until all surgical procedures performed by all surgical trainees are accurately audited and criteria for adequacy of operative training are clearly stated, it will not be possible to say whether our training programs provide adequate operative training or not. Accepted: 17 September 1998     

Doctoral clinical geropsychology training in a primary care setting

Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica, to clinical psychology doctoral students within a large urban professional psychology program. In an innovative effort to provide the most disadvantaged elderly with comprehensive mental health treatment and maximize trainee exposure to an interdisciplinary treatment model, the program also pairs selected doctoral psychology trainees with medical residents to optimize integrated mental health service delivery for primary care elderly. The program has the following core objectives: (1) Infuse the mental health and aging knowledge base into the regular graduate curriculum; (2) Provide interdisciplinary training in geropsychological diagnostic and consultative services within an urban primary care setting; (3) Provide interdisciplinary training in the practice of psychological and neuropsychological evaluation of elderly; (4) Provide training in geropsychological psychotherapeutic intervention, including individual, couples/family, and brief/psycho-educational therapies with outpatient older adults. These objectives are achieved by pooling the resources of a graduate school of psychology, a local public hospital, and an academic medical center to achieve educational and clinical service goals.     

Teaching Motivational Interviewing to Primary Care Staff in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) is implementing the patient-centered medical home (PCMH) model of primary care which emphasizes patient-centered care and the promotion of healthy lifestyle changes. Motivational Interviewing (MI) is effective for promoting various health behaviors, thus a training protocol for primary care staff was implemented in a VHA health care setting.

OBJECTIVES

We examined the effect of the training protocol on MI knowledge, confidence in ability to use MI-related skills and apply them to written vignettes, perceived comfort level and skill in lifestyle counseling, and job-related burnout.

DESIGN

Training was provided by experts in MI. The training protocol consisted of three sessions??one half day in-person workshop followed by a 60-minute virtual training, followed by a second workshop. Each of the sessions were spaced two weeks apart and introduced trainees to the theory, principles, and skills of using MI in health care settings.

PARTICIPANTS

All primary care staff at the Veterans Affairs Palo Alto Health Care System were invited to participate.

MEASUREMENTS

Trainees completed a short set of questionnaires immediately before and immediately after the training.

RESULTS

We found support for our primary hypotheses related to knowledge, confidence, and written responses to the vignettes. Changes in perceived comfort level and skill in lifestyle counseling, and job-related burnout were not observed.

CONCLUSIONS

Training primary care staff in MI is likely to become increasingly common as health care systems transition to the PCMH model of care. Therefore, it is important for health care systems to have low-cost methods for evaluating the effectiveness of such trainings. This study is a first step in developing a brief written assessment with the potential of measuring change in a range of behaviors and skills consistent with MI.