Bringing interdisciplinary and multicultural team building to health care education: the downstate team-building initiative.

PURPOSE: To evaluate the impact of the Downstate Team-Building Initiative (DTBI), a model multicultural and interdisciplinary health care team-building program for health professions students. METHOD: A total of 65 students representing seven health disciplines participated in DTBI's first three years (one cohort per year since implementation). During the 18-session curriculum, students self-evaluated their group's progress through Tuckman's four team-development stages (FORMING, STORMING, NORMING, PERFORMING) on an 11-point scale. Students completed matched pre- and postintervention program evaluations assessing five variables: interdisciplinary understanding, interdisciplinary attitudes, teamwork skills, multicultural skills, and team atmosphere. After participation, students completed narrative follow-up questionnaires investigating impact one and two years after program completion. RESULTS: Each year's team development curve followed a similar logarithmic trajectory. Cohort 1 remained in team development stage 3 (NORMING) while Cohorts 2 and 3 advanced into the final stage-PERFORMING. A total of 34 matched pre- and postintervention evaluations showed significant change in all major variables: Team atmosphere and group teamwork skills improved most (48% and 44%, respectively). Interdisciplinary understanding improved 42%. Individual multicultural skills (defined by ability to address racism, homophobia, and sexism) started at the highest baseline and improved the least (13%). Group multicultural skills improved 36%. Of 23 responses to the follow-up surveys, 22 (96%) stated DTBI was a meaningful educational experience applicable to their current clinical surroundings. CONCLUSIONS: DTBI successfully united students across health discipline, ethnicity, socioeconomic class, gender, and sexual orientation into functioning teams. The model represents an effective approach to teaching health care team building and demonstrates benefits in both preclinical and clinical years of training.     

Using the tool for assessing cultural competence training (TACCT) to measure faculty and medical student perceptions of cultural competence instruction in the first three years of the curriculum.

PURPOSE: To compare faculty and student perceptions of cultural competence instruction as measured by the AAMC's Tool for Assessing Cultural Competence Training (TACCT) as part of a comprehensive curricular needs assessment. METHOD: In 2005, 25 basic science and clinical course directors and 92 third-year medical students at the University of California, Irvine, School of Medicine were asked to indicate which of 67 separate items listed on the TACCT describing knowledge, skill, and attitude about cultural competence were covered during the first three years of the curriculum. The mean percentage of "yes" responses to each item was computed and compared for both faculty and students. RESULTS: Response rates were 100% (25/25) for course directors and 75% (69/92) for students. Students systematically perceived that cultural competence instruction occurred more often in the curriculum (range of 28% to 93% "yes" responses) compared to the faculty (range of 8% to 64%). However, faculty and students demonstrated a high level of concordance (intraclass correlation coefficient = 0.89 across all items) in their perceptions about instruction, as measured by their relative rank orderings of the 67 TACCT items. Students and faculty identified clusters of TACCT items pertaining to health disparities, community partnerships, and bias/stereotyping as least likely to be presented. CONCLUSIONS: Faculty and third-year students at one medical school responded congruently about the relative degree to which cultural competence instruction occurred. The TACCT can be used to identify significant gaps in cultural competence training and inform curricular revision. Further studies involving other schools are warranted.     

Medical students' cases as an empirical basis for teaching clinical ethics.

PURPOSE: To identify ethical issues that interns encounter in their clinical education and thus build a more empirical basis for the required contents of the clinical ethics curriculum. METHOD: The authors analyzed a total of 522 required case reports on ethical dilemmas experienced by interns from September 1995 to May 1999 at the medical school of Vrije Universiteit in Amsterdam. They identified four regularly described and numerous less frequently described topics. RESULTS: The interns addressed a wide range of ethical themes. In 45% of the cases, they mentioned disclosure or non-disclosure of information and informed consent; in 37%, medical decisions at the end of life; in 16%, medical failures; and in 9%, problems transferring patients from one caregiver to another. The interns also identified 27 themes linked to their unique position as interns and 19 themes related to specific types of patients. CONCLUSION: Based on self-reported experiences, the authors conclude that clinical ethics teachers should reflect on a multitude of dilemmas. Special expertise is required with respect to end-of-life decisions, truth telling, medical failures, and transferring patients from one caregiver to another. The clinical ethics curriculum should encourage students to voice their opinions and deal with values, responsibilities, and the uncertainty and failings of medical interventions.     

Implementation of geriatric education into the first and second years of a baccalaureate-MD degree program.

OBJECTIVE: As the population ages with an increasing standard of good health, medical students must redefine their views on aging and their approaches to aging and medicine. Consequently, the UM-KC School of Medicine has introduced an innovative approach to geriatric education. The approach seeks to help students view aging as a multidimensional process, challenge stereotypes about aging, learn about factors in healthy aging, and explore medical conditions of older patients. DESCRIPTION: To fulfill these objectives, each first- and second-year medical student (n = 200) in a six-year BA-MD degree program is paired with a mentor on aging. The mentor is an older adult living independently and experiencing normal psychosocial issues of aging without major medical problems. Over two years, students converse with their mentors about aging, keep journals reflecting on their conversations, complete projects with their mentors, and write scholarly papers. Thus, students can experience aging through their mentor relationships, gain an appreciation of their mentors' lives, and sharpen communication skills. In small groups, students and a physician-facilitator discuss problem-solving exercises keyed to American Geriatrics Society competencies and participate in an empathic aging exercise. Students also attend lectures on the care of older women and primary prevention. DISCUSSION: Assessment of students' performances is ongoing. Mentors have rated their students positively for being interested in them, being good listeners, and being eager to learn. Facilitators have rated most students highly for small-group participation. Instructors have reviewed and commented on student journals that suggest students have changed their stereotypes about older adults and appreciated the uniqueness of their mentors' lives. A performance-based assessment of the students' abilities to elicit life histories from senior volunteers will be administered halfway into the second year, and the scholarly papers will be critiqued at the end of the second year. Program evaluation is also under way. A pre-test of knowledge and attitudes showed students had little knowledge of the aging process, held negative stereotypes of older people, and preferred to care for younger patients. After-measures will be administered at the close of the second year. Evaluating their experience, mentors have said their interactions with students were enjoyable and beneficial to both parties. Students, while initially hostile because the program shifted their focus from sickly to healthy older adults, have found the evolving bonds between them and their mentors to be a benefit of the program. They believe that the most important lessons learned involved seeing the vitality and courage of older adults and improving their communication skills. Nevertheless, students feel they need more training in leading conversations and conducting interviews. Structured communication training will be added as the program continues to be a required part of the curriculum. Students have also thought the problem-solving cases should be more medically focused. While cases in the second year will emphasize medical aspects of aging, the cases in the first year will continue to explore psychosocial issues. Finally, to highlight psychosocial issues of aging, a session will be added utilizing a panel of older adults to provide examples and insights and to answer questions.     

Introducing technology into medical education: Two pilot studies

Objectives

Educators are integrating new technology into medical curriculum. The impact of newer technology on educational outcomes remains unclear. We aimed to determine if two pilot interventions, (1) introducing iPads into problem-based learning (PBL) sessions and (2) online tutoring would improve the educational experience of our learners.

Methods

We voluntarily assigned 26 second-year medical students to iPad-based PBL sessions. Five students were assigned to Skype for exam remediation. We performed a mixed-method evaluation to determine efficacy.

Results

Pilot 1: Seventeen students completed a survey following their use of an iPad during the second-year PBL curriculum. Students noted the iPad allows for researching information in real time, annotating lecture notes, and viewing sharper images. Data indicate that iPads have value in medical education and are a positive addition to the curriculum. Pilot 2: Students agreed that online tutoring is at least or more effective than in-person tutoring.

Conclusions

In our pilot studies, students experienced that iPads and Skype are beneficial in medical education and can be successfully employed in areas such as PBL and remediation.

Practice implications

Educators should continue to further examine innovative opportunities for introducing technology into medical education.     

Comparing self-reported communication skills of medical students in traditional and integrated curricula: a nationwide study

OBJECTIVES: To investigate medical students' self-assessments of their communication skills through medical school related to background factors, curriculum design and perceived medical school stress. METHODS: Medical students at all year levels attending Norwegian universities in the spring of 2003 were mailed the Oslo Inventory of Self-reported Communication Skills (OSISCS) developed by the authors. Of the total number of students (N=3055), 60% responded. One school had a traditional curriculum, the other three ran integrated models. RESULTS: Students assessed their instrumental communication skills to increase linearly year by year, while the relational skills showed a curve-linear trajectory reaching the optimum level half-way into the curriculum. Students attending the traditional school reported lower levels of instrumental skills compared to the students from the integrated schools. In relational skills, a similar difference was maintained half-way into the curriculum, but disappeared towards the end. Perceived medical school stress correlated to the self-reported end point levels of the two types of communication skills. DISCUSSION: The trajectories of self-reported instrumental and relational skills indicate significant variations in facilitating mechanisms between curricula, cognitive processing and perceived medical school stress. CONCLUSIONS: Self-reported instrumental and relational communication skills develop differently in medical students over the years according to the type of curriculum. PRACTICE IMPLICATIONS: Curricula should be evaluated for improvement implementations.     

"Advising Oliver Mann"--a case-based, small-group orientation to medical school.

In 1998, the authors implemented a new academic orientation built around a problem-based clinical exercise for entering medical students, to prepare them for a curriculum emphasizing active learning in small groups. The exercise enables students to begin their professional studies with a "hands on" understanding of two major emphases of the curriculum: (1) the process of small-group learning that will guide their medical education and (2) the principles of patient care that will guide their future practice of medicine. Called "Advising Oliver Mann," this orientation presents students with a clinical problem that they must work in small groups to solve. By collaborating in teams of ten, they become acquainted with the small-group learning methods at the heart of the school's curriculum. Through solving a clinical problem, they discover vital principles of patient care, such as the need in clinical decision making to integrate the scientific perspective with the perspective of patient and family. In developing "Oliver Mann," the authors came to realize that orientations can be much more than introductions. They can be reflective moments in a busy curriculum, a time for students and faculty to step back and take stock of important issues in education and doctoring. The authors are currently experimenting with exercises linking their freshman orientation with orientations in the second and third years so participants can reflect on the challenges of each new year and carry forward the small-group methods and practice of medicine themes of the new curriculum.     

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.     

Improving knowledge in palliative medicine with a required hospice rotation for third-year medical students.

PURPOSE: The Liaison Committee for Medical Education requires accredited U.S. and Canadian medical schools to teach end-of-life care. The purpose of this study was to evaluate a new required curriculum in palliative medicine for third-year medical students. METHOD: Beginning in July 2001, a required four-day (32 hour) curriculum was piloted as part of an ambulatory month in the 12-week medicine clerkship. Students spent Day 1 in the classroom learning core concepts regarding hospice, palliative care, and symptom management. A two-hour session with a standardized patient to break bad news was included. Students spent Days 2 and 3 making home visits or participating in inpatient care. Day 4 was spent in the classroom reviewing cases they had seen with interdisciplinary faculty, making presentations on assigned topics, and discussing professional self-care. Students completed a self-awareness project. Educational outcomes were measured with the students' completion of five pre- and postcourse assessment instruments: (1) self-assessment of competency, (2) attitudes, (3) concerns, (4) a 50-item, multiple-choice knowledge test, and (5) an assessment of elements of the course. RESULTS: Analysis of 127 paired evaluations showed significant improvements in three instruments: 56% improvement in competence (p <.0001), 29% reduction in concern (p <.0001), and 23% improvement in knowledge (p <.0001). There were no significant changes attitudes (p =.35). CONCLUSION: This 32-hour required curriculum in palliative medicine for third-year medical students improved knowledge. They came to the course with appropriate attitudes that did not change.     

Care at the end of life: a novel curriculum module implemented by medical students.

End-of-life (EOL) and palliative care education in medical school curricula stand at a crossroads. Consensus has emerged that these topics merit systematic instruction throughout medical school training, yet curricula all too often consist of sporadic lectures focused on bioethics instead of clinical skills. The medical student authors identified a deficit in their curriculum, and designed and implemented an EOL curriculum module for their colleagues. In early 2000 the authors surveyed senior medical students about their experiences with EOL and palliative education, identifying deficits in clinical training and recommendations for interventions. They then designed a case-based educational module to teach EOL communication skills to medical students commencing clinical training. Faculty with national and local experience with EOL and palliative care reviewed the curriculum. Twelve of these faculty were oriented to the curriculum and then taught it in pairs to groups of 12 to 16 medical students in 2000 and 2001. The curriculum develops skills, attitudes, and knowledge relevant for communicating bad news and establishing treatment options in the EOL setting by utilizing trigger videos, group discussion, role plays, and case discussions. Approximately 75% of the 86 eligible students attended the module in 2000 and 2001. Feedback has guided the curriculum's refinement by the medical student authors. In addition, a standardized patient exercise, introduced in 2001, allowed students to reinforce the skills learned during the module.     

Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and medical fallibility.

PURPOSE: To study the effects of a patient safety and medical fallibility curriculum on second-year medical students at the University of Missouri-Columbia School of Medicine in 2003-2004. METHOD: Students completed a knowledge, skills, and attitudes questionnaire before the curriculum, after the final learning experience, and one year later. A 95% confidence interval (CI) for paired differences assessed change over time. At one year, students also responded to items about their use of the curriculum, error reporting, and disclosure experiences. RESULTS: Fifty three of 92 students (55%) completed the questionnaire at all three assessment points. Students' eight items and the calculated knowledge score improved after the curriculum but only seven of these improvements were sustained one year. Responses to seven items did not change and five changed in an undesired direction after the curriculum and/or after one year. Seventy two students completed the self-reported behavior questions at one year. More than half reported using what they learned in the curriculum. Although 76% of students reported observing an error, 71% of these disclosed an error to their peers, 56% to a resident, and 46% to faculty. Only 7% reported an error using our electronic error reporting system. CONCLUSIONS: The curriculum led to changes in second-year medical students' knowledge, skills, and attitudes, but not all of the changes were sustained at one year, were in the desired direction, or were supported by their self-reported behaviors. The extent to which other informal or hidden curriculum experiences reversed the gains and affected the changes at one year is unknown.     

Introducing technology into medical education: Two pilot studies

ObjectivesEducators are integrating new technology into medical curriculum. The impact of newer technology on educational outcomes remains unclear. We aimed to determine if two pilot interventions, (1) introducing iPads into problem-based learning (PBL) sessions and (2) online tutoring would improve the educational experience of our learners.MethodsWe voluntarily assigned 26 second-year medical students to iPad-based PBL sessions. Five students were assigned to Skype for exam remediation. We performed a mixed-method evaluation to determine efficacy.ResultsPilot 1: Seventeen students completed a survey following their use of an iPad during the second-year PBL curriculum. Students noted the iPad allows for researching information in real time, annotating lecture notes, and viewing sharper images. Data indicate that iPads have value in medical education and are a positive addition to the curriculum. Pilot 2: Students agreed that online tutoring is at least or more effective than in-person tutoring.ConclusionsIn our pilot studies, students experienced that iPads and Skype are beneficial in medical education and can be successfully employed in areas such as PBL and remediation.Practice implicationsEducators should continue to further examine innovative opportunities for introducing technology into medical education.     

An investigation into medical students' approaches to anatomy learning in a systems-based prosection course

Students' approaches to learning anatomy are driven by many factors and perceptions, e.g., the curriculum, assessment, previous educational experience, and the influence of staff and fellow students. However, there has been remarkably little research into characterizing how students approach their anatomy learning. What is known, based on a sample of 243 students, is that students studying medicine at the University of Southampton adopt primarily a "deep" approach to learning. Medical students at Southampton learn anatomy in a systems-based curriculum through prosections. Analysis of data from an Approaches to Study Inventory (ASSIST) revealed that students preferred using a deep approach over a strategic or surface approach (P < 0.001 and P < 0.001, respectively). They also adopted an increasingly strategic approach as they moved through the medical curriculum. There was a relationship between anatomy examination results and approach to learning. Students who adopted a strategic approach performed better (R = 0.266, P < 0.001). It is argued that curriculum design, including the form of assessment, is the key to promote effective anatomy education and the goal of deep and meaningful learning in preparation for professional practice.     

Early clinical experience enhances third-year pediatrics clerkship performance.

PURPOSE: To determine whether clinical experiences in the preclinical years improve medical students' performances in a third-year clerkship. METHOD: A cohort study reviewed the pediatrics clerkship performances of 400 Eastern Virginia Medical School students in the graduating classes of 1996 through 1999. The first two classes completed a traditional preclinical curriculum with limited clinical experience. The final two classes participated in a mentorship program that provided 18 months of early clinical experience, consisting of one-on-one half-day sessions every other week with a generalist community faculty. The authors compared the clinical clerkship performances of the groups using clinical skills (CS) scores, history and physical examination (H&P) scores, and scores on the NBME pediatrics shelf examination. They also looked at the mean MCAT and USMLE scores for each group. The authors also looked at the scores within each class, comparing students who completed one of the first two pediatrics clerkship rotations with their classmates who completed clerkships later in the academic year. RESULTS: The students' NBME scores rose significantly (p < .05, r2 = 0.95) over the four-year study, paralleling a significant rise in MCAT scores (p < .03, r2 = 0.73). The CS and H&P scores did not rise. Students who had the traditional preclinical curriculum and who completed their clerkships early in the year had significantly lower CS and H&P scores than did their classmates. In contrast, the scores of students who had the early clinical experiences did not differ significantly according to the timing of their rotation. CONCLUSION: Students who had participated in a mentorship program that provided early clinical experience demonstrated significantly improved clinical skills in the pediatrics clerkship early in the academic year.     

Resources in bioethics at osteopathic medical schools.

PURPOSE: Medical students must have some exposure to bioethics, whether it be at the undergraduate or the postgraduate level. The authors sought to determine the range and ranking of topics taught in bioethics courses at U.S. osteopathic medical schools. METHOD: A qualitative study using a repeated-measures design was used to determine curricular offerings at all 19 U.S. osteopathic medical schools. Nominal groups were held to identify an initial topics list. A modified reactive Delphi technique was constructed and three survey iterations were administered. RESULTS: Bioethics is taught in all osteopathic medical schools, although the numbers of hours dedicated to the subject in the course of a four-year curriculum vary greatly (range 0-40). To further differentiate a curriculum in bioethics, the respondents were asked to rank bioethics topics as essential, foundational, or peripheral to the undergraduate medical curriculum. A total of 16 topics, including confidentiality, informed consent, truth-telling, death and dying, palliative care, and refusal of care, were identified as "essential" for a bioethics curriculum. CONCLUSIONS: Bioethics is taught at osteopathic medical schools, but further studies are needed to recommend guidelines to standardize the curriculum.     

A medical humanities special study module on principles of medical theory and practice at the Charité, Humboldt University, Berlin, Germany.

The authors are members of a committee in charge of a special study module (SSM) entitled Principles of Medical Theory and Practice in a problem-based and integrated reformed curriculum track at the Charité, the medical school and university hospital of the Humboldt University, Berlin, Germany. The SSM contextualizes medicine by highlighting the societal contexts of the doctor-patient relationship and the medical profession. Integrating the humanities into medical education helps students develop an awareness of the strengths and limitations of modern medicine, develop their own personalities and sense of social responsibility, and generally broaden their outlook. Teachers in the SSM seminars are from different disciplines, such as the history of medicine, bioethics, sociology, anthropology, and complementary medicine. Once a week, one or two teachers meet with as many as 21 students per group for a 90-minute course. Twelve courses constitute a seminar. Students are required to participate in four seminars during five years of studies. They can choose different topics from a set range. Although this SSM has been largely successful, some problems have occurred. Results from the course evaluations and experiences show that the seminars differ from one another in many ways. Financial restraints and the departmental structure of the faculty have influenced implementation of the SSM. However, the SSM is a new concept and is continuously reviewed and renewed. Future plans will be to specify outcomes, continue to discuss reasonable seminar topics, establish continuous support and training for teachers, and motivate students to become actively involved in the seminar discussions.     

Three domains of competency in global health education: recommendations for all medical students.

In the setting of world population growth and migration, global health issues have an increasing impact on domestic conditions and our medical practitioners. The authors ask: What exactly constitutes global health, and how much do U.S. and Canadian medical students or practitioners need to know about it? To address this topic, the authors convened an American Society for Tropical Medicine and Hygiene Committee on Medical Education, sought input from the Global Health Education Consortium, and surveyed members of the American Committee on Clinical Tropical Medicine and Travelers' Health for educational priorities within the tropical medicine field. The information gained from these sources has been distilled into three domains of global health competency that the authors propose each medical school curriculum should try to achieve for all students: global burden of disease, traveler's medicine, and immigrant health. The authors present here the rationale for altering curricula to include these three topics as a starting point for discussion among medical educators.