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Physicians at all levels of training sometimes feel more emotionally moved when viewing a movie about a patient than when treating a similar patient in an actual clinical encounter. The [...]

A major policy issue in the United States has become health care for the medically indigent. Persons without funds or insurance are not assured of receiving basic services or adequate health care. The burden of responsibility has come to rest on the local level and community-based coalitions have approached the problem with a variety of strategies. A summary of the history of advocacy efforts and a local background of how this problem has been addressed in Orange County, California are presented. Several approaches that were developed in conjunction with patients and private practitioners are outlined. Local advocacy efforts have provided modest improvements in opening health care services to the indigent. Increased funding for prenatal care and community clinics, expanding access and limiting restrictions on eligibility requirements have been some of the positive results. Many of the efforts by local advocates have been, out of necessity, defensive ones. This has hampered the development of programs with an emphasis on creative alternatives. Although there is evidence that community efforts are widespread, the lack of a well organized and broader based system restricts efforts to develop a national program that will provide universal entitlement to all individuals who reside in this country.

Background: Although program evaluation is a core requirement of Internal Medicine residencies, little is reported in the literature regarding resident satisfaction with training. Most program evaluation consists of numerical rating scales from which it is often difficult to pinpoint exact sources of dissatisfaction. Methods: Our goal in this work is to evaluate the utility of focus group methodology to uncover in detail the reasons for residents’ deteriorating morale in an IM residency program, as well as to solicit suggestions for correction. This study employed focus groups (FG) in a qualitative research design, in which descriptive statistics from a resident program evaluation survey served to guide an intensive focus group process. Participants were 40 of 45 2nd and 3rd year internal medicine residents enrolled in the IM residency training program. Five chief residents were trained to conduct 5 focus groups with 8 residents in each group. The focus groups examined possible issues contributing to the deterioration of morale noted in the quantitative survey. Results: Many unexpected themes were uncovered by the FGs. Residents identified the following factors as the major contributors to deteriorating morale: 1) Pace of change 2) Process of change 3) The role of chief residents in change 4) Fear of intimidation and retaliation. Groups also suggested practical recommendations for improving the culture of the residency. Conclusion: Introducing change in residency training is a challenging process. Respectful attention to resident frustrations and solution-focused discussions are necessary to understand and improve morale. Focus groups proved to be a useful tool in revealing the precise source of pervasive resident concerns as well as providing potential solutions. In addition, FGs methodology can be adapted in a practical manner to residency evaluation. [ABSTRACT FROM AUTHOR]

Context: Although interest exists among medical educators in using writing that reflects on clinical experience to enhance medical students' communication skills, empathy, and overall professionalism, little empirical research documents the value of this approach. This study explored whether students trained in one type of writing would first demonstrate increased awareness of emotional aspects of a clinical encounter in their writing; and second, be evaluated more positively in an OSCE situation by standardized patients. Method: Ninety-two students were assigned to either a point-of-view writing or a clinical reasoning condition as part of a second year doctoring course. At the end of the year, students were evaluated in an OSCE format on 3 cases, and completed a writing assignment about an ER death from cardiac arrest. Student essays were scored according to presence or absence of various themes. A linguistic analysis of the essays was also performed. Point-of-view and clinical reasoning group scores were compared on both measures, as well as on the standardized patient OSCE ratings. Results: Students trained in point-of-view writing demonstrated significantly more awareness of emotional and spiritual aspects of a paper case in a writing assignment than did students trained in clinical reasoning. By contrast, students in the clinical reasoning group were more likely to distance from the scenario. The two groups did not differ on SP OSCE ratings. Conclusion: Training in point-of-view writing can improve medical students' written skills on certain affective dimensions. It is not clear that these skills can translate into clinical behavior. [ABSTRACT FROM AUTHOR]

The authors describe a longitudinal third- and fourth-year elective, ‘The Art of Doctoring’, introduced in an attempt to counteract perceived frustration and cynicism in medical students at their home institution during the clinical years. The course goals aimed at helping students to develop self-reflective skills; improve awareness of and ability to modify personal attitudes and behaviors that compromise patient care; increase altruism, empathy and compassion toward patients; and sustain commitment to patient care, service and personal well-being. These goals were accomplished through introduction and development of five skill sets: learning from role models and peers; on-site readings of works by medical student- and physician-authors; self- and other-observation; self-reflective techniques; and case-based problem-solving. The course involved regular in-class exercises and homework assignments, as well as a personal project related to improving personal compassion, caring and empathy toward patients. Students also learned to use a coping algorithm to approach problematic clinical and interpersonal situations. Class discussions revealed three issues of recurring importance to students: loss of idealism, non-compliant patients, and indifferent, harsh or otherwise unpleasant attendings and residents. Quantitative and qualitative student evaluations overall indicated a generally favorable response to the course. Problems and barriers included attendance difficulties and variable levels of student engagement. Future directions for this type of educational intervention are considered, as well as its implications for medical education. [ABSTRACT FROM AUTHOR]

Background: Although resident physicians often teach, few trials have tested interventions to improve residents' teaching skills. A pilot trial in 2001-2002 found that 13 trained resident teachers taught better than did untrained control residents.Objective: To determine whether a longitudinal residents-as-teachers curriculum improves residents' teaching skills.Design: Randomized, controlled trial from May 2001 to February 2002 (pilot trial) and March 2002 to April 2003.Setting: 4 generalist residencies affiliated with an urban academic medical center.Participants: 62 second-year residents: 23 in the 2001-2002 pilot trial and 39 more in 2002-2003; 27 of the 39 participants were medicine residents required to learn teaching skills.Intervention: A 13-hour curriculum in which residents practiced teaching and received feedback during 1-hour small-group sessions taught twice monthly for 6 months.Measurements: A 3.5-hour, 8-station, objective structured teaching examination that was enacted and rated by 50 medical students before and after the intervention. Two trained, blinded raters independently assessed each station (inter-rater reliability, 0.75).Results: In the combined results for 2001-2003, the intervention group (n = 33) and control group (n = 29) were similar in sex, specialty, and academic performance. On a 1 to 5 Likert scale, intervention residents outscored controls on overall improvement score (post-test-pretest difference, 0.74 vs. 0.07; difference between intervention and control groups, 0.68 [95% CI, 0.55 to 0.81]; P < 0.001) by a magnitude of 2.8 standard deviations and on all 8 individual stations. The intervention residents improved 28.5% overall, whereas the scores of control residents did not increase significantly (2.7%). In 2002-2003, 19 intervention residents similarly outscored 19 controls (post-test-pretest difference, 0.83 vs. 0.14; difference between intervention and control groups, 0.69 [CI, 0.53 to 0.84]; P < 0.001). Twenty-seven medicine residents required to learn teaching skills achieved scores similar to those of volunteers.Limitations: The study was conducted at a single institution. No "real life" assessment with which to compare the results of the objective structured teaching examination was available.Conclusions: Generalist residents randomly assigned to receive a 13-hour longitudinal residents-as-teachers curriculum consistently showed improved teaching skills, as judged by medical student raters. Residents required to participate improved as much as volunteers did. [ABSTRACT FROM AUTHOR]

Compares the academic performance of internal medicine residents with their specific teaching behaviors in Irvine, California. Utilization of baseline teaching videotapes; Correlation between the academic performance and teaching behavior of internal medicine residents; Evaluation of medical students' global ratings of residents' teaching skills.