Tracking the Contribution of a Family Medicine
Clerkship to the Clinical Curriculum
Sue A. Maple, PhD; Thomas A. Jones, MD; Terrence
J. Bahn, EdD; Richard D. Kiovsky, MD; Brenda S. O’Hara, MD;
Stephen P. Bogdewic, PhD
Background and Objectives: Medical educators
are working to articulate the objectives and measure the outcomes
of medical education. In clinical training, faculty need methods
to identify both the principal educational contributions of
individual clerkships and how prior experiences influence
student learning.
Methods: We analyzed students’ perceived acquisition
of clinical knowledge and skills on a 4-week, community-based
family medicine clerkship. The data represent 349 third-year
medical students who participated in the clerkship during
a 2-year time period. Results were summarized by three different
combinations of prior clerkship experiences and overall.
Results: Students reported gains as a result of the
clerkship for the majority of medical problems and procedures.
However, there were differences in the clerkship’s perceived
contribution depending on the timing and sequence of clinical
rotations. Even when the family medicine clerkship followed
all other primary care rotations, students perceived that
the clerkship contributed to gains in knowledge of undifferentiated
and commonly seen problems; applications of health promotion,
disease prevention, and patient education; importance of family
dynamics in patient care; business aspects of medical practice;
and appreciation of family practice.
Conclusions: The results demonstrate how a required
family medicine clerkship can enhance the clinical learning
that occurs on other rotations. The study also demonstrates
that it is possible to track a clerkship’s contribution to
student development and to understand how a clerkship’s role
may change according to students’ prior experiences.
Educational Research and
Methods
(Fam Med 1998;30(5):332-7.)
Use of an Objective
Structured Clinical Examination in Evaluating Student Performance
Michael D. Prislin, MD; Camille F.
Fitzpatrick, NP, MSN; Désirée Lie, MD; Mark Giglio, MD; Stephen
Radecki, PhD; Ellen Lewis, RN, MSN
Background and Objectives: The objective
structured clinical exam (OSCE) is increasingly being used
to evaluate student clinical performance. However, scant literature
exists pertinent to this approach in evaluating family medicine
clerkship performance. In this study, we assess 8 years’ experience
with a family medicine clerkship OSCE.
Methods: Eight annual clerkship
OSCEs and the performance of 696 students are described. Comparisons
of faculty evaluation, written exam, and OSCE performance
are made for 335 students. Post-OSCE student and faculty feedback
regarding OSCE validity and utility is also presented.
Results: Student performance
is highest in medical history taking and physical examination
and lowest in information-sharing stations. OSCE results appear
to be relatively consistent on a year-to-year basis. OSCE,
faculty evaluation, and written exam results have low overall
levels of correlation, particularly in assessing performance
that differs substantially from the mean. Students and faculty
agree that the OSCE experience reflects skills that students
should possess, but there is less agreement that the OSCE
reflects clerkship-related learning and actual student performance.
Both students and faculty derive insight from the OSCE regarding
the definition of specific learning needs.
Conclusions: The
family medicine clerkship OSCE we describe appears to provide
consistent measures of student performance. Although content
validity is high, further assessment is needed to assure construct
validity. The OSCE experience provides students with a rich
resource for defining clerkship-related learning needs. Study
results strongly suggest that OSCEs, faculty evaluations,
and written exams provide differing measures of student performance.
The reasons for these differences merit further exploration.
Educational Research and Methods
(Fam Med 1998;30(5):338-44.)
Integrating Osteopathic
Training Into Family Practice Residencies
Kenneth H. Johnson, DO; James A. Raczek,
MD; Daniel Meyer, PhD
Background and Objectives:
Since the mid-1980s, the number of osteopathic
graduates has increased, and the number of osteopathic hospitals
has decreased. This has led to an increasing number of osteopathic
students seeking training in Accreditation Council for Graduate
Medical Education (ACGME) family practice residency programs.
In response to these developments and to a declining pool
of allopathic applicants in the early 1990s, at least 35 ACGME
programs have completed the American Osteopathic Association
(AOA) accreditation process as approved internship sites.
This article describes 1) the rationale for becoming accredited,
2) the AOA accreditation process, 3) a model osteopathic curriculum,
4) potential difficulties, 5) issues to consider in approaching
a decision to become AOA accredited, and 6) future trends
in osteopathic graduate medical education.
Educational Research and Methods
(Fam Med 1998;30(5):345-9.)
Assessing Colposcopic
Skills: The Instructor’s Handbook
Gregory L. Brotzman, MD; Barbara S.
Apgar, MD, MS
Background and Objectives:
In the United States, 93% of family
practice residency programs teach colposcopy. Training should
ideally include didactic teaching of basic knowledge, followed
by practice on models and then supervised teaching with patients.
Although various curricula have been published that outline
basic principles of colposcopy education, methods of determining
clinical competency among resident physicians are lacking.
Methods of assessing psychomotor and cognitive skills in colposcopy
are available for instructors, including the use of preclinical
cervical practice models for colposcopic biopsy and endocervical
curettage, visual skills tests that use images of colposcopic
findings, colposcopy CD-ROMs, written pretest and posttest
knowledge assessment instruments, and procedural checklists.
Specific parameters for many of these tools can be used to
define clinical competency in colposcopy.
Educational Research and Methods
(Fam Med 1998;30(5):350-5.)
Predicting Resident
Confidence to Lead Family Meetings
Dennis J. Butler, PhD, MSW; Richard
L. Holloway, PhD; Mark Gottlieb, PhD
Background and Objectives:
Family physicians frequently encounter patients’ family members
in family meetings regarding health care. Although residents
are expected to learn how to interview families, no quantitative
studies have examined variables associated with building residents’
confidence in their ability to lead family meetings. The current
study sought to clarify the relationship between a number
of training, participant, and situational components and resident
confidence.
Methods: All family practice
residents (n=90) in a five-residency program system were sent
a survey that examined their experience in and perceived competence
to conduct family meetings. Responses were analyzed with a
hierarchical regression analysis and an ex post facto univariate
analysis.
Results: Residents with higher
perceived confidence in their ability to run a family meeting
were male, had specific training for leading family meetings,
had participated in and initiated more family meetings, perceived
stronger family physician faculty support, and had more family
systems training than lower-confidence residents.
Conclusions: The
results highlight the experiential, curricular, and environmental
variables that are associated with building resident confidence
to lead family meetings. Residents may benefit from early
exposure to the skills needed for family meetings and from
reinforcement of these skills through observations of skilled
practitioners, the expectation that they will initiate meetings,
and the opportunity to debrief meetings with supportive faculty.
Family meeting curricula should include conflict management
skills and incorporate input from other specialists and hospital
personnel who meet with families.
Educational Research and Methods
(Fam Med 1998;30(5):356-61.)
Validity of the
Medical Outcomes Study Depression Screener in Family Practice
Training Centers and Community Settings
Rollin Nagel, MA; Denis Lynch, PhD;
Marijo Tamburrino, MD
Background and Objectives:
Screening inventories that identify
primary care patients suffering from depression should be
brief, correlate with depression diagnoses, and be evaluated
in populations with whom the inventories will be used.
Methods: A total of 566 patients from
a medical school training center and 457 patients from six
community family practice offices completed the Medical Outcomes
Study (MOS) depression screener and a questionnaire reporting
demographic information and health habits. All subjects scoring
above the recommended screener cut-off, and a random sample
of those scoring below, were interviewed with the Diagnostic
Interview Schedule (DIS).
Results: A total of 195 subjects from
the training center and 147 from the community sample were
called and administered the DIS. About 33% of the training
center and 25% of the community sample scored above the cutoff.
Of those above the cutoff and administered the DIS, 23% of
the training center and 10% of the community sample were diagnosed
with either major depression or dysthymia.
Conclusions: The MOS screener was an
effective method of identifying depressed subjects in the
training center and community settings. However, because of
the relatively low prevalence of depression in these settings,
a relatively high number are falsely screened positive. Identifying
these patients as having subthreshold depressive symptoms
and the necessity/efficacy of treatment is controversial,
as is the use of screening instruments. The simplified MOS
scoring strategy and template used in this study would probably
increase its usefulness in the primary care setting.
Clinical Research and Methods
(Fam Med 1998;30(5):362-5.)
Prevalence of
and Factors Associated With Current and Lifetime Depression
in Older Adult Primary Care Patients
Kristen Lawton Barry, PhD; Michael F.
Fleming, MD, MPH; Linda Baier Manwell; Laurel A. Copeland,
MPH; Scott Appel, MS
Background and Objectives:
Depression in late life is a significant
health problem in the United States. This study examined the
relationship between depression and alcohol, cigarette use,
family history, and sociodemographic factors in older adult
primary care patients.
Methods: As part
of a larger clinical trial, 2,732 patients in 24 primary care
offices were recruited to complete a self-administered health
screening survey. Depression was assessed using Diagnostic
and Statistical Manual of Mental Disorders, Third Edition,
Revised (DSM-III-R) criteria for lifetime and current depression.
Results: A total of 17.8% of females
and 9.4% of males age 60 and over met DSM-III-R criteria for
lifetime depression; 10.6% of the females and 5.7% of the
males met current depression criteria. Depression was significantly
and positively correlated with female gender and family history
of mental health problems and negatively correlated with social
contact.
Conclusions: Older
adults, especially women, should be considered at elevated
risk for depression when a family history of mental health
problems and self-report of inadequate social connection can
be established.
Clinical Research and Methods
(Fam Med 1998;30(5):366-71.)
Russian Family Practice
Training Program: A Single Step on a Long Journey
Gerald J. Jogerst, MD; Susan Lenoch, MA; John W. Ely,
MD, MSPH
Background and Objectives:
Since 1992, when the Russian government
recognized family practice as a medical specialty, efforts
have begun to progress from the idea stage to the delivery
of patient care via family practice methods. We describe an
educational effort to help teach Russian physicians family
practice skills.
Methods: Five
young Russian physicians were selected from an initial pool
of 15 candidates on the basis of standardized testing, English
language skills, and their potential to teach future Russian
family physicians. Clinical, teaching, and business curricula
were developed and used during the 6-month training period
for the five selected physicians. Trainees were evaluated
by mentors’ and preceptors’ written evaluations and by the
American Board of Family Practice In-training Examination
before, during, and at completion of the training. Subsequently,
a fully equipped family practice office was opened in St Petersburg
to serve as an on-site training facility.
Results: The
trainees’ self-perceived knowledge in community medicine,
geriatrics, medical decision making, patient education, behavioral
science, preventive medicine, and general family practice
topics improved over the course of training. The composite
scores on the in-training examinations improved from baseline
(30 versus 308). Preceptors noted the greatest improvements
in the use of clinical instruments, proficiency in physical
exams, accessing medical information, and formulating differential
diagnoses. The St Petersburg family practice office opened
on October 1, 1996. The trainees now participate in the care
of patients in this office and teach a new class of family
medicine interns.
Conclusions: The
training program we describe has allowed Russian physicians
to acquire new skills and knowledge that they can use and
adapt to training future Russian family physicians.
International Family Medicine
(Fam Med 1998;30(5):372-7.)
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