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Despite evidence-based recommendations for communication and decision making about life-sustaining treatment, resident physicians' actual practice may vary. Few prior studies have examined these conversations qualitatively to uncover why ineffective communication styles may persist.To explore how discussions about life-sustaining treatment occur and examine the factors that influence physicians' communicative practices in hopes of providing novel insight into how these processes can be improved. PARTICIPANTS AND APPROACH: We conducted and recorded 56 qualitative semi-structured interviews with participants from 28 matched dyads of a resident physician and a hospitalized patient or their surrogate decision maker with whom cardiopulmonary resuscitation was discussed. Transcripts were analyzed and coded using the constant comparative method to develop themes.Resident physicians introduced decisions about resuscitation in a scripted, depersonalized and procedure-focused manner. Decision makers exhibited a poor understanding of the decision they were being asked to make and resident physicians often disagreed with the decision. Residents did not advocate for a particular course of action; however, the discussions of resuscitation were framed in ways that may have implicitly influenced decision making.Residents' communication practices may stem from their attempt to balance an informed choice model of decision making with their interest in providing appropriate care for the patient. Physicians' beliefs about mandatory autonomy may be an impediment to improving communication about patients' choices for life-sustaining treatment. Redefining the role of the physician will be necessary if a shared decision making model is to be adopted.

RIME is a descriptive framework in which students and their teachers can gauge progress throughout a clerkship from R (reporter) to I (interpreter) to M (manager) to E (educator). RIME, as described in the literature, is complemented by residents and attending physicians meeting with a clerkship director to discuss individual student progress, with group discussion resulting in assignment of a RIME stage.1) to determine whether a student's RIME rating is associated with end-of-clerkship examination performance; and 2) to determine whose independent RIME rating is most predictive of a student's examination performance: attendings, residents, or interns.Prospective cohort study.Third year medical students from academic years 2004-2005 and early 2005-2006 at 1 medical school.Each attending, resident, and intern independently assessed the student's final RIME stage attained. For the purpose of analysis, R stage=1, I=2, M=3, and E=4. Regression analyses were performed with examination scores as dependent variables (National Board of Medical Examiners [NBME] medicine subject examination and a clinical performance examination [CPE]), with independent variables of mean attending RIME score, mean resident score, and mean intern score. For the 122 students, significant predictors of NBME subject exam score were resident RIME rating (p = .008) and intern RIME rating (p = .02). Significant predictor of CPE performance was resident RIME rating (p = .01).House staff RIME ratings of students are associated with student performance on written and clinical skills examinations.

Sexual history and HIV counseling are essential clinical skills. Our project's purpose was to evaluate a standardized patient (SP) educational intervention teaching third-year medical students sexual history taking and HIV counseling. A 4-hour SP workshop was delivered to one-half of the class. Four weeks later, all students engaged in an SP examination including one station on assessing sexual history taking and HIV counseling. Workshop participants scored one standard deviation higher on sexual history and HIV counseling items than nonparticipants. Our sexual history and HIV counseling curriculum was associated with students asking more thorough sexual histories and providing more HIV counseling.

To review the impact of the clinical education of internal medicine residents on patients' outcomes.English-language studies of the relation between internal medicine housestaff training and patients' outcomes were systematically identified by a MEDLINE search and from bibliographies and reference lists of recently published articles.We hypothesized that the primary impact of internal medicine residency training on patients' outcomes would be the result of: (1) the inexperience of the residents; (2) the heavy workload these inexperienced residents are expected to manage: or (3) some structural feature of the internal medicine teaching services, such as the discontinuity of patient care inherent in night float systems and the fact that residents rotate to different services each month. We also hypothesized that residents may in may ways provide superior care, and many actually improve certain patient outcomes. Housestaff inexperience, workload, and structural features that promote discontinuity have been shown to affect especially outcomes of resource utilization, length of stay, and patient satisfaction. No study has demonstrated that internal medicine residents contribute to excess patient morbidity or mortality. However, the published studies in this area are for the most part retrospective and were conducted 10 to 15 years ago. The full extent of the untoward (or the beneficial) effects of internal medicine residency training on patients' outcomes is unknown.Multisite, prospective studies would remedy the deficiencies in the published research in this area and would yield the most valid insight into the range and extent of the effects of housestaff training on patients' outcomes. In the absence of such studies and in a rapidly changing managed care environment, academic medical centers and departments of medicine need to be aware of those aspects of the clinical education of residents that are most likely to affect patients' outcomes.

To determine if fourth-year medical students are as effective as faculty in teaching the physical examination to first-year medical students.Stratified randomization of the first-year students.A public medical school.All 100 first-year medical students in one medical school class were randomly assigned (controlling for gender) to either a faculty or a fourth-year student preceptor for the Physical Examination Module.The first-year students of faculty preceptors scored no differently on the written examination than the students of the fourth-year medical student preceptors (82.8% vs 80.3%, p = .09) and no differently on a standardized patient practical examination (95.5% vs 95.4%, p = .92). Also, the first-year students rated the two groups of preceptors similarly on an evaluation form, with faculty rated higher on six items and the student preceptors rated higher on six items (all p.10). The fourth-year student preceptors rated the experience favorably.Fourth-year medical students were as successful as faculty in teaching first-year medical students the physical examination as measured by first-year student's performances on objective measures and ratings of teaching effectiveness.

The Rapid Estimate of Adult Literacy in Medicine (REALM-R), a new 8-item instrument designed to rapidly screen patients for potential health literacy problems, was administered to 157 patients. The REALM-R was correlated with Wide Range Achievement Test-Revised (WRAT-R) (.64) and demonstrated a Cronbach's alpha of 0.91. The REALM-R identified 26 of 30 persons scoring more than 1 standard deviation below the mean on the WRAT-R, corresponding to a sixth grade reading level. The REALM-R identified a substantial number of people who scored poorly on the WRAT-R, and depending on further studies of validity and reliability, may offer a practical approach to identify patients at risk for health literacy problems in a clinical setting.

To examine the association of physician nonverbal communication with standardized patient (SP) satisfaction in the context of the "quality" of the interview (i.e., information provided and collected, communication skills).Observational.One university-based internal medicine residency program.Fifty-nine internal medicine residents. INTERVIEWING: The 59 residents were recruited to participate in 3 SP encounters. The scenarios included: 1) a straightforward, primarily "medical" problem (chest pain); 2) a patient with more psychosocial overlay (a depressed patient with a history of sexual abuse); and 3) a counseling encounter (HIV risk factor reduction counseling). Trained SPs rated physician nonverbal behaviors (body lean, open versus closed body posture, eye contact, smiling, tone of voice, nod, facial expressivity) in the 3 encounters. Multiple regression approaches were used to investigate the association of physician nonverbal behavior with patient satisfaction in the context of the "quality" of the interview (SP checklist performance, measures of verbal communication skills), controlling for physician characteristics (gender, postgraduate year).Nonverbal communication skills was an independent predictor of standardized patient satisfaction for all 3 patient stations. The effect sizes were substantial, with nonverbal communication predicting 32% of the variance in patient satisfaction for the chest pain station, 23% of the variance for the depression-sexual abuse station, and 19% of the variance for the HIV counseling station.Better nonverbal communication skills are associated with significantly greater patient satisfaction in a variety of different types of clinical encounters with standardized patients. Formal instruction in nonverbal communication may be an important addition to residency.