Graduates of internships and coordinated undergraduate programs--do differences exist?

Two principal routes have existed for several years for gaining credentials for dietetic practice, the dietetic internship and the coordinated program. However, comparative evaluations of the effectiveness of these programs in preparing entry-level practitioners have been limited. In this study, adequacy of educational preparation and performance of dietetic internship and coordinated program graduates was assessed at entry level and after one year of practice, using graduates' self-ratings and supervisors' evaluations. The majority of graduates who were employed in dietetic practice held clinical positions in hospitals or university medical centers. Educational preparation and level of performance of all graduates were considered to be adequate, indicating that both types of programs are preparing knowledgeable and competent entry-level practitioners. Although differences on competency measures were not reflected at entry level, intern graduates scored significantly higher than graduates of coordinated programs on administrative and clinical competencies after one year of practice. Also, at entry level and after one year, those completing internships were rated higher on two performance style measures: initiative/self-assurance and dependability. In general, supervisors' ratings tended to be higher than graduates' self-ratings.     

Intervening with Practitioners to Improve the Quality of Prevention: One-Year Findings from a Randomized Trial of Assets-Getting To Outcomes

There continues to be a gap in prevention outcomes achieved in research trials versus those achieved in “real-world” practice. This article reports interim findings from a randomized controlled trial evaluating Assets-Getting To Outcomes (AGTO), a two-year intervention designed to build prevention practitioners’ capacity to implement positive youth development–oriented practices in 12 community coalitions in Maine. A survey of coalition members was used to assess change on individual practitioners’ prevention capacity between baseline and one year later. Structured interviews with 32 program directors (16 in the intervention group and 16 in the control group) were used to assess changes in programs’ prevention practices during the same time period. Change in prevention capacity over time did not differ significantly between the intervention and control groups. However, in secondary analyses of only those assigned to the AGTO intervention, users showed greater improvement in their self-efficacy to conduct Assets–based programming and increases in the frequency with which they engaged in AGTO behaviors, whereas among non-users, self-efficacy to conduct Assets–based programming declined. Interview ratings showed improvement in several key areas of performance among intervention programs. Improvement was associated with the number of technical assistance hours received. These results suggest that, after one year, AGTO is beginning to improve the capacity of community practitioners who make use of it.     

The relationship of tutors' content expertise to interventions and perceptions in a PBL medical curriculum

This study addressed three questions: (1) Do content-expert tutors differ from non-expert tutors in the extent to which they present/explain case content? (2) Do tutors who present/explain case content differ from those who almost never do in their ratings of various outcomes of a PBL curriculum? (3) Are tutors who present/explain case content rated differently by students from tutors who almost never do? Data were gathered from 88 tutors and 168 students in the first 2 years of a PBL medical curriculum. Students assessed their tutor after each unit, and tutors completed a questionnaire near the end of the academic year. In this study, `content expertise' was defined operationally as tutors' self-ratings on the question `To what extent could you teach (at the Med I level) the material covered in the cases?' Less than half of the tutors reported that they almost never presented/explained case content. As tutors' content expertise increased, they tended to present/explain case content more frequently. Tutors who almost never presented/explained case content rated PBL more highly than traditional methods. No differences were found in student ratings of tutors who almost never presented/explained case content, compared to tutors who did. The results suggest that tutors who are content experts find it difficult to maintain the `facilitator' role, but that those who maintain this role are more satisfied with PBL. It appears that other tutor behaviours may have a greater influence on students' ratings of their tutors.     

An experimental study of the influence of individual participant characteristics on formal consensus development

OBJECTIVES: The aim of this study was to examine the influence of participants' characteristics on the results produced by formal consensus methods. METHODS: The approach was an experimental study of 346 participants in 20 groups rating the appropriateness of four mental health interventions for the treatment of chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain. There were four factors in the design: systematic literature review provided or not, decisions made under realistic or "ideal" resource assumptions, clinically mixed (general practitioners and mental health professionals) or homogenous group (general practitioners only), convened or mail-only group. A group's rating was defined as the median of participants' ratings. The influence of participants' characteristics (age, sex, and specialty) was examined using multilevel models. RESULTS: The largest differences were between the GPs and mental health professionals, both in their initial ratings of the different interventions, and in how much they altered their ratings between rounds. There were smaller but statistically significant (p<.05) differences between specialty and age groups in initial ratings for the treatment (by whatever means) of different conditions, and for certain conditions women increased their ratings more than men. Women rated intervention more favorably when assuming "ideal" rather than realistic levels of resources, but men did not. CONCLUSIONS: Our findings support the practice of treating professional specialty as an important determinant of the results in consensus panels.     

Community coalition project directors: what makes them effective leaders?

OBJECTIVE: Effective leaders, both voluntary and paid, facilitate successful coalitions. The attributes that characterize effective project directors, however, are unclear. Our aim was to identify characteristics of effective project directors leading community coalitions. METHODS: The study examined 13 project directors who led eight community-based coalitions established to combat substance abuse. We inductively identified common characteristics and leadership effectiveness of the project directors by abstracting data from detailed ethnographic studies of these coalitions. We assessed the validity of leadership effectiveness by comparing data abstracted from ethnographic studies with two independent ratings. We then employed a cross-case comparison strategy for analyzing patterns among the common characteristics identified and leadership effectiveness. Six characteristics emerged among the project directors studied: status with community (insider vs outsider); shared leadership; bridge building skills; substance abuse expertise; vision; and management style. RESULTS AND CONCLUSIONS: Shared leadership, bridge building skills, and insider status were consistently related to leadership effectiveness. Less support was found for substance abuse expertise or vision. When hiring project directors, coalition leaders may consider assessing whether candidates are "insiders" within the community and demonstrate shared leadership and bridge building skills.     

Public health skills in primary care in South West England--a survey of training needs, obstacles and solutions.

The UK government is moving primary care towards a more health needs led service. This will require a greater awareness of public health skills among primary care staff. We therefore sent a postal questionnaire to the chairmen of primary care groups (general practitioners), the chief officers of primary care groups, directors of public health, nurse advisors of health authorities, directors of community nursing and directors of midwifery in the South West region of England. Respondents were asked about skills in health needs assessment, health service planning and other public health skills among general practitioners, health visitors and midwives. The survey also covered perceived obstacles to the acquisition of such skills and possible solutions. The response rate was 67% (96/143). Eighty percent of primary care groups returned at least one reply. Sixty-four percent had either not considered the problem or considered it but not acted. Fifty percent of directors of public health felt that they could not provide more training to non-specialist staff. Most organisations provided little training in public health skills to non-specialist staff despite a perceived skill shortage particularly in health promotion, advocacy and the evaluation of the effectiveness and efficiency of services. We conclude that primary care groups and public health departments need to agree how to access public health advice. Primary care groups need to identify individuals with an interest in strategic working and service planning, identify their skill deficits and seek appropriate training.     

Comparing self- and supervisor evaluations: a different view.

Studies comparing self- and supervisor evaluations of performance during medical training have generally indicated a lack of congruence between the two sets of ratings. A possible explanation is that supervisors may make evaluations on the basis of an overall impression whereas self-evaluations are more sensitive to differences between performance in different areas. Support for this explanation was indicated by consistently higher correlations among supervisor ratings of 13 performance areas for first-year residents. Support was also indicated by separate factor analyses of supervisor and self-ratings of 13 areas, in that two factors were identified for supervisors whereas there were three for self-ratings. It was concluded that the data supported the notion that self-ratings were more discriminating than supervisors' in evaluating resident performance across a number of performance areas.     

Perspectives on lifestyle intervention: the views of general practitioners who have taken part in a health promotion study

AIM: A study was carried out to discover the views of Danish general practitioners on the possibility of intervening in their patients' lifestyles in general and on the obstacles to doing so, based on their experience of participating in a health promotion study. METHOD: A focus group interview was conducted with five general practitioners who had participated in "The Ebeltoft Health Promotion Study" to assess their views on their preventive role. RESULTS: The general practitioners have internalized the view advanced by society and the medical profession that they have an important role to play in preventing lifestyle-related illness. However, they are sceptical about the effectiveness of intervention and have ethical concerns about giving lifestyle advice. They are also somewhat irritated by the fact that patients are chiefly interested in having their health checked, rather than in following up by changing their behaviour. The general practitioners differ in their views as to when, and how actively, they should initiate discussions with individual patients to encourage them to change their lifestyles. CONCLUSIONS: If the medical profession and those responsible for overall health policy wish to make general practitioners change their behaviour towards their patients, it is important that they understand the aims, values, and working conditions of general practitioners that underlie their present attitudes and behaviour.     

Problem solving styles of general practitioners in simulated clinical situations

Self-assessments were received from 210 general practitionersresponding to a series of six patients management problems publishedin a Norwegian medical journal. The physicians were invitedto give their ratings on a five-point rating scale for 21 to24 statements relating to each of the six case histories. Fromthese ratings an answer index was prepared which measured thedegree of decisiveness for each individual physician. The respondingphysicians showed great variations in their problem solvingstyles. Physicians with a high degree of decisiveness in theirproblem solving styles had significantly longer experience asgeneral practitioners, were older and were more likely to workin single-handed practices rather than group or partnershippractices. Sex, practice economy and work load were some ofthe variables not related to the observed differences in problemsolving styles.     

Differences in innovation-related characteristics between singleskilled and multiskilled health practitioner educational programs.

A survey of educational programs preparing single- and multiskilled health practitioners was conducted to determine the predictive power of organizational formalization and centralization and individual program director cosmopolitanism (ie, orientation to their larger profession as opposed to local environment) upon readiness to innovate for the educational units. Questionnaires were sent to 45 directors of programs preparing multiskilled health practitioners and 49 directors of programs preparing singleskilled health practitioners. Results indicated no significant differences between program directors of single- and multiskilled programs in their perceptions of the readiness to innovate for their educational units. Regression analysis indicated that a decentralized organization was a predictor of an educational unit's readiness to innovate. This finding held for both single- and multiskilled programs. Although cosmopolitanism was not a significant predictor of readiness to innovate, program directors at four-year institutions had a significantly higher level of that characteristic than directors at two-year institutions. The results of this study, although limited by individual and not multiple responses from each institution, do not indicate any differences in the ability of organizational formalization and centralization to predict the innovative characteristics of single- and multiskilled allied health programs. Additionally, the cosmopolitanism of program directors also does not predict these same characteristics.     

An empirical definition of “primary care”

An operational definition of primary care, useful to a wide variety of professionals, has eluded researchers since the term first gained popularity. This paper presents an activity-based definition of primary care derived from ratings of 59 representative health care activities by a group of state health administrators, a group of local health department directors, and a random sample of primary care physicians practicing in North Carolina. Thirty-one activities received ratings indicating they were considered core primary care services. Examination of differences in ratings among the three groups surveyed suggests that health department directors differ from the other two groups. Consideration of the variances of activity ratings within the groups emphasizes the unique response of the health department directors and identifies activities characterized by considerable disagreement.The study includes information necessary for researchers and practitioners to form an activity-based definition of varying scope. Definitions constructed from this information should be useful in planning the evaluation efforts that involve different groups of providers, since activities provide an objective basis for agreement. Repeating the approach outlined in the paper with other provider groups in other areas of the country should lead to better understanding of intergroup and regional differences in the concept of primary care.Dr. Farrow is Clinical Associate Professor, Dr. Harrison is Postdoctoral Fellow, Dr. Kaluzny is Professor, and Ms. Newsome is Research Assistant, all with the Department of Health Administration, School of Public Health, and the Health Services Research Center, University of North Carolina at Chapel Hill, 27514. This work was supported in part by grant number HS 01971 to the Health Services Research Center of the University of North Carolina at Chapel Hill from the National Center for Health Services Research, Department of Health, Education, and Welfare. Correspondence and reprint requests should be addressed to Arnold Kaluzny, Department of Health Administration, School of Public Health, University of North Carolina, Chapel Hill, NC 27514.     

Validity of self-assessed physical fitness.

This study compared self-ratings of components of physical fitness with objective measures of physical fitness. We made comparisons in two groups of male infantry soldiers (n = 96 and n = 276) and one group of older male military officers (n = 241). To obtain self-ratings of physical fitness, we asked subjects, "Compared to others of your age and sex, how would you rate your (a) endurance, (b) sprint speed, (c) strength, (d) flexibility?" Subjects responded to each of the four questions on a five-point scale. Self-ratings of endurance were systematically related to three measures of aerobic capacity, including VO2max, peak VO2, and two-mile run time (r = 0.29 to 0.53). Self-ratings of sprint speed showed only weak relationships to measures of anaerobic capacity assessed by the Wingate test, push-ups, and sit-ups (r = 0.10 to 0.17). Strength ratings were systematically related to measures of maximal strength (r = 0.28 to 0.53). Upper body strength measures were more closely associated with the self-ratings of strength than were measures of lower body strength. Responses to the flexibility question were systematically related to measures of hip/low back flexibility (r = 0.30 and 0.48) but not to other measures of flexibility. Apparently, physically active subjects can approximately classify their aerobic capacity, muscle strength, and some types of flexibility.     

Long-term sick-listing, medical rehabilitation and life quality change: a patient evaluation.

This evaluation of the health service at one of the hospitals of the National Insurance Board in Sweden is primarily based on the perspective of the patient. One interview group of 32 patients (I-group) made life quality ratings before-after their hospital stay. In responding to a postal questionnaire one year after discharge from hospital, another group of 93 former patients (Q-group) made parallel self-ratings. Due to prolonged sick-listing, the patients had been admitted to the hospital for rehabilitation/examination according to paragraph 2:11 in the general insurance law. The basis for their sick-listing was hereby critically reviewed. Within the framework of additional examinations (interview and structured general questions), more than 40% of the respondents stated that the hospital stay was mainly satisfying and a great majority appreciated the nursing care. However, the self-ratings showed that the patients did not ascribe any particularly great significance to the hospital stay. In the short term, it even seemed to have a certain negative impact on the life quality of the patients. No obvious positive bias seems to be built into the ratings. Thus, the assessment package applied may also work well in similar evaluative settings.     

The attributes of an effective teacher differ between the classroom and the clinical setting

Most training programs use learners’ subjective ratings of their teachers as the primary measure of teaching effectiveness. In a recent study we found that preclinical medical students’ ratings of classroom teachers were associated with perceived charisma and physical attractiveness of the teacher, but not intellect. Here we explored whether the relationship between these variables and teaching effectiveness ratings holds in the clinical setting. We asked 27 Internal Medicine residents to rate teaching effectiveness of ten teachers with whom they had worked on a clinical rotation, in addition to rating each teacher’s clinical skills, physical attractiveness, and charisma. We used linear regression to study the association between these explanatory variables and teaching effectiveness ratings. We found no association between rating of physical attractiveness and teaching effectiveness. Clinical skill and charisma were independently associated with rating of teaching effectiveness (regression coefficients [95 % confidence interval] 0.73 [0.60, 0.85], p < 0.001 and 0.12 [0.01, 0.23], p = 0.03, respectively). The variables associated with effectiveness of classroom and clinical teachers differ, suggesting context specificity in teaching effectiveness ratings. Context specificity may be explained by differences in the exposure that learners have to teachers in the classroom versus clinical setting—so that raters in the clinical setting may base ratings upon observed behaviours rather than stereotype data. Alternatively, since subjective ratings of teaching effectiveness inevitably incorporate learners’ context-specific needs, the attributes that make a teacher effective in one context may not meet the needs of learners in a different context.     

Professional performance of physician's assistants: a comparison of physician's assistant and physician ratings.

Physician's assistant educational programs have used surveys of their graduates as one method of evaluating educational objectives and curricula. A concern is the validity of physician's assistant self-ratings as measures of job performance. Ratings by supervising physicians have been suggested as more valid measures. In the present study ratings of physician's assistants and their supervising physicians were compared. Physician's assistants and their supervising physicians were interviewed using an interview instrument developed to cover the performance of the physician's assistant in the major activities of primary care practice. While the physicians and physician's assistants disagreed on several measures, in all cases the ratings of the physician's assistants were more conservative. Thus, the physician's assistants did not show any tendency to inflate ratings of their own performance.     

Psychological adjustment in children with end stage renal disease: the impact of maternal stress and coping

OBJECTIVE: To explore maternal and child perspectives on children's adjustment in the context of paediatric renal disease, and maternal psychological variables that may account for variance in child and maternal ratings. METHODS: Forty-three children with end stage renal disease and their maternal caregivers completed the Strengths and Difficulties Questionnaire (SDQ). Mothers also reported on their own mental health, and the strategies they used to cope with their child's illness.The severity of the child's condition was rated independently by a renal clinician. RESULTS: Compared with normative data for the SDQ mothers reported their children to be at increased risk of psychological problems. However, the children themselves reported no more problems than a normative sample. Mothers' coping and mental health explained some of the variance in their ratings of the child's adjustment but were not predictive of the children's self-ratings. CONCLUSIONS: The results suggest that maternal factors may not explain the variability in children's adjustment to chronic illness, perhaps especially within the age range studied here. Practical implications of the data are also discussed. In particular, a systemic approach to paediatric liaison by psychologists is emphasized.     

Comparison of subjective ratings of function with observed functional ability of frail older persons.

BACKGROUND. Important clinical decisions often hinge on patients' functional status. Previous studies have shown disagreement among sources of ratings of patients' functional status. This study compared patient self-ratings, family member ratings, and physician ratings of patient function to performance-based functional testing criteria. METHODS. Five activities of daily living of 73 older patients were studied at admission to a rehabilitation unit following discharge from an acute care community hospital. Data were collected from patients, family members, and physicians and were compared with performance-based function testing. RESULTS. Patient ratings were significantly more accurate than physician ratings for walking, transferring, and telephoning. Patients were significantly more accurate than family members for rating walking and telephoning, but patients were not significantly more accurate than family members or physicians for rating eating or dressing. CONCLUSIONS. We conclude that decisions about patients' functional level should be based on performance testing. If performance testing is unavailable, patients' own ratings are most accurate, followed by family ratings. Physicians' ratings are least accurate.     

Perceptions of competency attainment in clinical dietetics: academic Plan IV vs. dietetic internships

A national survey of all Plan IV representatives and dietetic internship directors in programs with a general or clinical emphasis was conducted to determine the level of competence in clinical dietetics expected of Plan IV graduates. Dietetic interns were asked to rate themselves on competency attainment at the beginning and near the end of the internship. The ADA's Role Delineation Study for Entry-level Personnel in Clinical Dietetics was used as the basis for the survey questionnaire. Completed questionnaires were returned by 137 Plan IV representatives (54%), 71 dietetic internship directors (75%), and 530 dietetic interns (62%). Highly significant differences were found among the three groups. Plan IV representatives had higher expectations of students than internship directors. Interns consistently rated their competency levels for all responsibilities below those indicated by either group of directors. All three groups indicated that students were better prepared for client-focus responsibilities than for professional or organizational-level responsibilities. Interns' self-ratings suggested that similar amounts of learning occurred in each of the three areas during the internship. Nutrition-related work experience immediately prior to the internship influenced students' perceived competency level at the beginning of the internship, but differences between those students and the ones with other or no work experience were overcome as students neared the end of their internships. For most major responsibilities, the students' perceived levels of competence did not change after the first few months of the internship.     

Cultivating next generation leadership: preceptors' rating of competencies in post-graduate administrative residents and fellows

Substantial national attention is being directed at enhancing the competency levels of early careerists in healthcare management. In this study, we examined preceptors' ratings of administrative resident/fellow competencies in multiple domains, and we compared those to our previous results of self-rated competency by residents/fellows. In this national sample of preceptors (n=61) of administrative residency/fellowship program listed with the American College of Healthcare Executives, competency in the information management domain was ranked highest, with more than half of preceptors (55.7%) giving their residents/fellows an "A" rating. Fewer preceptors (between 30.0% and 39.2%) gave their residents/fellows an "A" rating in domains of interpersonal and emotional intelligence, analytic and conceptual reasoning, and clinical operations. Less than 20% of preceptors rated competencies as "A" level in the domains of human resources/marketing/public affairs, financial management, fund raising, and facilities management. There were significant differences in preceptor ratings compared with resident/fellow self-ratings, with preceptors often providing lower ratings than provided by resident/fellows. The findings highlight the need not only to enhance competency levels of graduates but also to address the potential mismatch in early careerists' and preceptors' views about required and attained competency levels.