A web-based system for students to document their experiences within six core competency domains during all clinical clerkships.

The authors describe the design and implementation of a new Web-based system that allows students to record important features of their clinical encounters during all 10 required clinical clerkships, document their learning experiences in six major competency domains, and generate detailed real-time reports for themselves and their clerkship directors. A new Web-based system, DMEDS (Dartmouth Medical Encounter Documentation System), accepts input from computers and PDAs. Its design permits students to describe their patients, learning sites, interactions with preceptors, and important aspects of their clinical encounters in all of our medical school's competency domains. Using a common format for all required clerkships, clerkship directors select specific items most relevant to their clerkships from a common menu and set learning targets for specific diagnoses and clinical skills. This new system was designed in the fall of 2003, tested in the spring of 2004, and implemented in all clerkships for the 2004 to 2005 academic year.During the first full academic year that DMEDS was used, students documented nearly 32,000 discrete student-patient-preceptor encounters, an average of between 21 and 120 clinical encounters per Year 3 clerkship. Highlights of the analysis of these initial data include the following: (1) insights into how educational targets are set, (2) the extent of site-to-site variation in clerkship experiences, (3) the epidemiology of patients' declining student involvement, and (4) student experiences in and understanding of the newer competency domains.DMEDS can be used in all clinical clerkships and can address student experiences in all competency domains. It provides substantial value to students, clerkship directors, preceptors, and medical school administrators. As secondary benefits, the authors found that DMEDS facilitates educational research and is readily adapted for use in residency and fellowship programs as well. Student feedback highlights the need to pay close attention to the time invested by students documenting their clinical encounters. Course directors must ensure that the benefits to students (such as knowledge of meeting learning targets and preceptors providing direct feedback to students) are transparent. Finally, for other schools contemplating the change to a competency-based curriculum with the use of a clinical encounter documentation system, the time required for both students and faculty to adopt and fully engage these major educational culture shifts seems to be at least several years.     

Using formal evaluation sessions for case-based faculty development during clinical clerkships.

Developing housestaff and faculty in their roles as medical educators is a dynamic process. The rigorous clinical evaluation method used during the third-year internal medicine clerkship at the Uniformed Services University uniquely incorporates faculty development into the process of evaluation and generating feedback for students. Formal evaluation sessions are held monthly at all clerkship sites throughout the 12-week clerkship and are moderated by either the internal medicine clerkship director or the on-site clerkship directors. Although designed to provide an opportunity for faculty to evaluate student performance and prepare formative feedback, the sessions also function as formal, planned, and longitudinal forums of "real-time," "case-based" faculty development that address professional, instructional, and leadership development. The evaluation sessions are used as a means to model and teach the key concepts of the Stanford Faculty Development Program. Providing a unifying form of evaluation across multiple teaching sites and settings makes formal evaluation sessions a powerful, state-of-the-art tool for faculty development.     

Weaving women's health across clinical clerkships.

Clerkship directors have an opportunity to develop consensus on learning objectives for women's health issues and to develop curricula that cross disciplinary boundaries. A collaborative interdisciplinary approach assures proper sequencing of knowledge and skill acquisition, conserves educational resources, and reflects the values of connectedness and patient-centeredness that are central to women's health. The informal networks and the institutional structures that bring clerkship directors together for discussion of a variety of educational issues promote such collaboration. The authors describe three approaches to designing and implementing women's health curricula and discuss how each might be applied to the topic of domestic violence: adding free-standing courses to existing curricula, often as electives; delegating pieces of the women's health curriculum to existing courses; and creating new interdisciplinary curricula that then are integrated into the general curriculum. Each has advantages and disadvantages. Ideally, models for curriculum design will reflect the collaborative patient-centered models upon which the field of women's health is based. Such models enhance program effectiveness by taking advantage of discipline-based expertise while allowing for the sharing of both educational responsibilities and educational resources.     

Using a web-based system for the continuous distance education in cytopathology

Background

The evolution of information technologies and telecommunications has made the World Wide Web a low cost and easily accessible tool for the dissemination of information and knowledge. Continuous Medical Education (CME) sites dedicated in cytopathology field are rather poor, they do not succeed in following the constant changes and lack the ability of providing cytopathologists with a dynamic learning environment, adaptable to the development of cytopathology. Learning methods including skills such as decision making, reasoning and problem solving are critical in the development of such a learning environment.

Objectives

The objectives of this study are (1) to demonstrate on the basis of a web-based training system the successful application of traditional learning theories and methods and (2) to effectively evaluate users’ perception towards the educational program, using a combination of observers, theories and methods.

Implementation

Trainees are given the opportunity to browse through the educational material, collaborate in synchronous and asynchronous mode, practice their skills through problems and tasks and test their knowledge using the self-evaluation tool. On the other hand, the trainers are responsible for editing learning material, attending students’ progress and organizing the problem-based and task-based scenarios. The implementation of the web-based training system is based on the three-tier architecture and uses an Apache Tomcat web server and a MySQL database server.

Methods

By December 2008, CytoTrainer's learning environment contains two courses in cytopathology: Gynaecological Cytology and Thyroid Cytology offering about 2000 digital images and 20 case sessions. Our evaluation method is a combination of both qualitative and quantitative approaches to explore how the various parts of the system and students’ attitudes work together.

Results

Trainees approved of the course's content, methodology and learning activities. The triangulation of evaluation methods revealed that the training program is suitable for the continuous distance education in cytopathology and that it has improved the trainees’ skills in diagnostic cytopathology.

Conclusions

The web-based training system can be successfully involved in the continuous distance education in cytopathology. It provides the opportunity to access learning material from any place at any time and supports the acquisition of diagnostic knowledge.     

Using digital videos displayed on personal digital assistants (PDAs) to enhance patient education in clinical settings

OBJECTIVES: To evaluate the effects of using an audiovisual animation (i.e., digital video) displayed on a personal digital assistant (PDA) for patient education in a clinical setting. METHODS: Quasi-experimental study of a prospective technology intervention conducted in an outpatient infectious diseases clinic at an academic medical center. Subjects responded to questions immediately before, immediately after, and 4-6 weeks after watching a digital video on a PDA. Outcome measures include participant knowledge of disease, knowledge of medications, and knowledge of adherence behaviors; attitudes toward the video and PDA; self-reported adherence; and practicality of the intervention. RESULTS: Fifty-one English-speaking adults who were initiating or taking medications for the treatment of HIV/AIDS participated in the study. At visit one, statistically significant improvements in knowledge of disease (p<0.005; paired t-test), knowledge of medications (p<0.005; paired t-test), and knowledge of adherence behaviors (p<0.05; ANOVA) were measured after participants watched the PDA-based video. At visit two (4-6 weeks later), statistically significant improvements in self-reported adherence to the medication regimens (p<0.005; paired t-test) were reported. Participants liked the PDA-based video and indicated that it was an appropriate medium for learning, regardless of their baseline literacy skills. The video education process was estimated to take 25 min of participant time and was viewed in both private and semi-private locations. CONCLUSIONS: Technology-assisted education using a digital video delivered via PDA is a convenient and potentially powerful way to deliver health messages. The intervention was implemented efficiently with participants of a variety of ages and educational levels, and in a range of locations within clinical environments. Additional study of this methodology is warranted.     

Using web-based animations to teach histology

We have been experimenting with the use of animations to teach histology as part of an interactive multimedia program we are developing to replace the traditional lecture/laboratory-based histology course in our medical and dental curricula. This program, called HistoQuest, uses animations to illustrate basic histologic principles, explain dynamic processes, integrate histologic structure with physiological function, and assist students in forming mental models with which to organize and integrate new information into their learning. With this article, we first briefly discuss the theory of mental modeling, principles of visual presentation, and how mental modeling and visual presentation can be integrated to create effective animations. We then discuss the major Web-based animation technologies that are currently available and their suitability for different visual styles and navigational structures. Finally, we describe the process we use to produce animations for our program. The approach described in this study can be used by other developers to create animations for delivery over the Internet for the teaching of histology.     

Time allocation of students in basic clinical clerkships in a traditional curriculum.

The objective of this study was to determine the amounts of time spent in various activities by medical students enrolled in basic clinical clerkships. In the fall of 1989, 80 third-year students at the University of North Carolina at Chapel Hill School of Medicine recorded their time allocations in eight categories over 24 hours for three consecutive days. After personal time, the students spent the greatest amount of time in organized educational activities (rounds, conferences, lectures), followed in decreasing order by chartwork, patient contact, examination study, ancillary activities, procedures, and directed study. The students reported an average of 5.8 hours of sleep per night. The students reported that when they were on call, they had significant increases in patient contact, chartwork, and ancillary activities. The authors suggest that third-year students may spend too much of their time in organized educational activities, and may benefit educationally from increased amounts of patient contact and decreased amounts of ancillary activities. These data provide an opportunity for clerkship and curriculum organizers to analyze the efficacy of the basic clinical clerkships.     

Using early clinical experiences to integrate quality-improvement learning into medical education.

Health care providers are delivering care in an increasingly complex environment; this requires that providers develop new competencies to better understand their work and to design changes that can help them succeed. Recognizing these new educational requirements, Dartmouth Medical School created a model two-pronged program for teaching quality improvement to its medical students. The goal of the program is to provide students with an active learning experience as well as an education in the theory and application of continuous quality improvement. The program includes two educational experiences: one curriculum is for all medical students and the other is for selected, highly motivated students. The first curriculum is incorporated in Dartmouth's required "On Doctoring" course, in which students spend time with community-based physician preceptors. The quality-improvement curriculum is designed around an improvement project developed at the students' preceptor sites. The second curriculum for students with a special interest in quality improvement is offered as an elective summer program between the first and second years of medical school. Working in groups of two, students identify an area for improvement within a preceptor's practice, assist the practice in articulating an improvement plan, help implement that plan, and write up their experiences. The authors describe the two curricula, factors associated with their successful implementation, and lessons learned.     

Problem based teaching and learning as a bridge from basic anatomy to clinical clerkships

This article describes a Clinical Anatomy course designed to bridge basic anatomy with clinical clerkships. It is given in the second year, after the traditional dissecting anatomy course. Students revisit anatomy during small group discussions of clinical cases. An example of a case is described together with a summary of a typical group process stimulated by the case. The group process enables students to develop clinical thinking and problem solving skills fundamental to clinical practice. They learn to search for medical knowledge resources, and to work in teams. The tutor evaluates the students’ progress based on their knowledge building, problem solving and development of their interpersonal skills. Problem based learning in this interdisciplinary anatomy course allows students and faculty both horizontal and vertical integration within the curriculum.     

The experiential health information processing model: supporting collaborative web-based patient education

Background  

First generation Internet technologies such as mailing lists or newsgroups afforded unprecedented levels of information exchange within a variety of interest groups, including those who seek health information. With emergence of the World Wide Web many communication applications were ported to web browsers. One of the driving factors in this phenomenon has been the exchange of experiential or anecdotal knowledge that patients share online, and there is emerging evidence that participation in these forums may be having an impact on people's health decision making. Theoretical frameworks supporting this form of information seeking and learning have yet to be proposed.     

Piloting a web-based continuing professional development program for asthma education

PURPOSE: Continuing professional development is an integral component of modern medical practice, yet traditional educational methods are impractical for many Primary Care Physicians. Web-based programs may fulfill the requirements of busy practitioners who have difficulty attending formal education sessions. METHODS: We piloted the use of a learning management system to deliver asthma education materials to Primary Care Physicians in both Australia and Italy in their native languages. Each group of Physicians accessed an education module which contained content pages, self-tests, a quiz and a survey. Details of how the Physicians used the system, their preferences and performance on the assessment were monitored. RESULTS: The learning management system was well received by both Italian and Australian Physicians. Thirty-eight (18 Australian, 20 Italian) Physicians used the system. Participants visited an average of 8.8 pages, with a mean time per hit of 2.9 min. Formative assessment was undertaken by 63.2% and summative assessment by 68.4% of participants. There were no substantial differences in performance between Physicians from both countries. Italian physicians tended to use the system after hours whereas Australian Physicians appear to do so between patient visits. CONCLUSIONS: Simple web-based systems are suitable for delivering educational materials to Primary Care Physicians in a manner likely to be used.     

Changing attitudes about end-of-life decision making of medical students during third-year clinical clerkships.

To better define the learning objectives of ethics curricula and evaluate changes in medical students' attitudes about end-of-life decision making, enrolled students (N = 96) of a pilot medical ethics program were surveyed at the beginning and end of their third-year clinical clerkship about their experiences and attitudes about end-of-life decision making. At the end of their clinical clerkship year, the majority of students had participated in end-of-life decisions, prioritized patient autonomy and quality-of-life issues, were concerned about legal liability, were polarized over issues such as physician-assisted suicide, and gained confidence in their ethical decision-making ability. To train future physicians such that clinical practice is consistent with ethical guidelines and legislation on end-of-life care, medical ethics curricula should focus on symptom relief, clarification of legal issues, and resolution of conflicts between personal beliefs and public opinion about such issues as physician-assisted suicide. Appropriate role-modeling and mentoring by residents and attending physicians should also be emphasized.     

A thematic approach to enhance clinical content in a cell and tissue biology course.

OBJECTIVE: (1) To integrate clinical problem solving into freshman cell and tissue biology (CTB) and (2) to enhance understanding of diabetes using CTB principles to explain the etiology, management, and development of complications in terms of cell, tissue, and organ structure and function. DESCRIPTION: First-year medical students often question the need to learn detailed basic science material. Although clinical content has increased throughout basic science courses, little attempt has been made to link clinical correlations to one another or to enhance use of basic science material in clinical problem solving. The CTB course applies pertinent cell biology concepts such as cell proliferation, differentiation, migration, adhesion, and morphogenesis to tissue and organ function. Diabetes mellitus was chosen as a theme for CTB as diabetes has devastating effects on multiple tissues, and the disease has reached epidemic proportions in the United States, affecting individuals of every age and population group. Type I diabetes, presenting as ketoacidosis in a ten-year-old boy, was introduced by generalist physicians using a "grand rounds" approach. This format challenged students on the first day of medical school to diagnose a patient's problem and to explain the clinical findings in terms of anatomic, biochemical, and physiologic changes. The role of the blood/bicarbonate buffering system was the main focus of faculty-led discussion. The patient was then presented at age 25 with many diabetic complications. This stimulated discussion of the etiology of diabetes (type I versus type II), glycation, and the use of hemoglobin (Hb) A1c to monitor blood sugar control. Compliance and other aspects of diabetes management were added to the discussion. Faculty provided scientific information as necessary, and summary materials were distributed after the sessions. The interaction of a cell biologist with two generalist physicians optimized the integration of basic science with clinical problem solving. During the two semesters of CTB, the diabetes case is frequently referenced. Insulin synthesis provides the model for protein synthesis. Glycation, advanced glycation end products (AGE), and receptors (RAGE) are discussed. Other diabetes-related topics include wound healing (epithelium), basement membrane thickening (connective tissue), insulin regulation of muscle metabolism, diabetic neuropathy (neurohistology), platelet adhesiveness, glycation and HbA1c (blood), osteoporosis and Charcot joints (skeletal system), autoimmune mechanisms (cellular immunology), atherosclerosis and high blood pressure (blood vessels), diabetic nephropathy (renal), altered hepatic and gastrointestinal function, impotence (male reproductive system), and a comparison of type I and type II diabetes (endocrine system). DISCUSSION: Students have provided very positive feedback. The initial case enhanced interest in CTB, established clinical relevance, and has motivated learning and integration of materials from different parts of CTB and other courses. Other courses are now formally linking to the theme. For example, neuroscience will revisit diabetic neuropathy and retinopathy, physiology will relate ketoacidosis to acid-base balance, a human anatomy clinical correlation is being designed for transplantation surgeons to "cure" our diabetic patient with a renal-pancreas transplant. Uses of the case for introduction to clinical medicine, aspects of medical ethics, preventive medicine, and courses in pharmacology and pathology are contemplated.     

Using mixed methods to design a web-based behavioural intervention to reduce transmission of colds and flu

This mixed methods study informed the development of our web-based intervention to reduce the risk of transmission of respiratory infections. Two qualitative studies examined 28 users' responses to website materials, and elicited additional beliefs. A questionnaire study (N = 129) tested key intervention assumptions: that hand-washing is considered the most feasible preventive behaviour; behavioural determinants were related to behavioural intentions; beliefs related to hand-washing intentions and behaviour. Thematic analysis of the qualitative data revealed important issues, such as the belief that catching minor infections is beneficial to the immune system. The questionnaire results confirmed our assumptions, including hand-washing as the appropriate target behaviour.     

NCCAM awards grants to CAM institutions to enhance research education

While these initiatives are targeting different levels and types of students and are employing a wide range of curricular strategies and teaching methodologies, all of the institutions are focusing heavily on preparing graduates who are skilled in health informatics and able to employ EBM in their clinical practice. In various ways, all of the PIs have voiced the need to change the culture of the institution and their profession, thus making faculty development perhaps the most important component of their grant effort. Several of the institutions are piloting highly innovative approaches to teaching and faculty development, and the efforts of all seem to be enriched and enhanced by the opportunity that they have to partner with a research-intensive university. We are encouraged by these pioneering efforts and believe that collaborative efforts such as these will significantly impact integrative health and medicine.     

Teaching communication in clinical clerkships: models from the macy initiative in health communications.

Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination. In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.