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To explore faculty perspectives on which characteristics of high-performing clerkship students are most important when determining an honors or top grade designation for clinical performance.In 2016-2017, the authors surveyed faculty (teaching ward attendings) for internal medicine clerkships and 1 pediatrics clerkship in inpatient settings at 5 U.S. academic medical centers. Survey items were framed around competencies, 24 student characteristics, and attitudes toward evaluation. Factor analysis examined constructs defining high-performing students.Of 516 faculty invited, 319 (62%) responded. The top 5 characteristics as rated by respondents were taking ownership, clinical reasoning, curiosity, dependability, and high ethical standards (in descending order). Twenty-one characteristics fit into 3 factors (Cronbach alpha, 0.81-0.87). Clinical reasoning did not fit into a factor. Factor 1 was the most important (mean rating, 8.7/10 [95% confidence interval (CI), 8.6-8.8]). It included professionalism components (ownership, curiosity, dependability, high ethical standards), presentation and interviewing skills, seeking feedback, and documentation. Factor 2 (mean, 7.9 [95% CI, 7.7-8.0]) included aspects of teamwork and communication, such as positive attitude and comments from others. Factor 3 (mean, 7.6 [95% CI, 7.4-7.7]) addressed systems-based thinking, including patient safety and care transitions.Professionalism components, clinical reasoning, and curiosity were among the most important characteristics distinguishing high-performing clerkship students. These may represent behaviors that are highly valued, observable, and relevant to training stage. Improved definition of the characteristics associated with clinical honors would assist students, faculty, and residency program directors when interpreting clinical performance within core clerkships.

Purpose: End-of-life and palliative care (EOL/PC) education is a necessary component of undergraduate medical education. The extent of EOL/PC education in internal medicine (IM) clerkships is unknown. The purpose of this national study was to investigate the presence of formal EOL/PC curricula within IM clerkships; the value placed by IM clerkship directors on this type of curricula; curricular design and implementation strategies; and related barriers and resources. Method: The Clerkship Directors in Internal Medicine conducted its annual survey of its institutional members in April 2012. The authors analyzed responses to survey items pertaining to formal EOL/PC curriculum and content using descriptive statistics. The authors used qualitative techniques to analyze free-text responses. Results: The response rate was 77.0% (94/122). Of those responding, 75.8% (69/91) believed such training should occur in the IM clerkship, and 43.6% (41/94) reported formal curricula in EOL/PC. Multiple instructional modalities were used to deliver this content, with the majority of programs dedicating four or more hours to the curriculum. Curricula covered a wide range of topics, and student assessment tools were varied. Most felt that students valued this education. The qualitative analysis revealed differences in the values clerkship directors placed on teaching EOL/PC within the IM clerkship. Conclusions: Although many IM clerkship directors have implemented formal curricula in EOL/PC, a substantial gap remains between those who have implemented and those who believe it belongs in the clerkship. Time, faculty, cost, and competing demands are the main barriers to implementation.

Inconclusive findings about infection risks, importantly the use of immunosuppressive medications in patients who have undergone large-joint total joint arthroplasty, challenge efforts to provide evidence-based perioperative total joint arthroplasty recommendations to improve surgical outcomes. Thus, the aim of this study was to describe risk factors for developing a post-operative infection in patients undergoing TJA of a large joint (total hip arthroplasty, total knee arthroplasty, or total shoulder arthroplasty) by identifying clinical and demographic factors, including the use of high-risk medications (i.e., prednisone and immunosuppressive medications) and diagnoses [i.e., rheumatoid arthritis (RA), osteoarthritis (OA), gout, obesity, and diabetes mellitus] that are linked to infection status, controlling for length of follow-up.A retrospective, case-control study (N = 2212) using de-identified patient health claims information from a commercially insured, U.S. dataset representing 15 million patients annually (from January 1, 2007 to December 31, 2009) was conducted. Descriptive statistics, t-test, chi-square test, Fisher's exact test, and multivariate logistic regression were used.Male gender (OR = 1.42, p0.001), diagnosis of RA (OR = 1.47, p = 0.031), diabetes mellitus (OR = 1.38, p = 0.001), obesity (OR = 1.66, p0.001) or gout (OR = 1.95, p = 0.001), and a prescription for prednisone (OR = 1.59, p0.001) predicted a post-operative infection following total joint arthroplasty. Persons with post-operative joint infections were significantly more likely to be prescribed allopurinol (p = 0.002) and colchicine (p = 0.006); no significant difference was found for the use of specific disease-modifying anti-rheumatic drugs and TNF-α inhibitors.High-risk, post-operative joint infection groups were identified allowing for precautionary clinical measures to be taken.

This journal watch feature sponsored by the Alliance for Clinical Education provides brief summaries of selected medical education articles that were published in internal medicine specialty journa...

Those with chronic diseases, including inflammatory bowel disease (IBD), often do not receive preventive care at the same rate as the general population. Attitudes of primary care providers could be key factors in the receipt of preventive care. We surveyed attendees of a family medicine review course. The survey contained nine demographic items, four items to assess exposure to and comfort level with IBD, and six clinical vignettes. Of surveys, 36% (61/169) were returned. The large majority were males practicing outpatient family medicine. Mean age was 51 years, and 48% reported a mostly rural practice. Of subjects, 10% reported either having IBD themselves or having a close associate or relative with IBD. Only 37% of subjects felt comfortable providing primary care across a range of illness severity. Forty-six percent reported moderate or high exposure to IBD. For the case vignettes, the overall highest rate of endorsement of the active role was 84% for a case related to stage I hypertension, while the lowest rate was 30% for an item relating to vaccination for immunosuppressed persons. We assessed the following predictors of comfort level and active role responses and found no significant associations: age, gender, years of medical practice, and close contact with IBD. Our study suggests that family medicine practitioners often do not feel comfortable providing care to IBD patients. Lack of familiarity with IBD medications may be a key factor.

Background: Persons with chronic diseases often do not receive preventive care at the same rate as the general population. Reasons for this are not clear. We conducted a cross-sectional survey of patients with inflammatory bowel disease (IBD) and controls to assess receipt of 10 preventive health services. Methods: From March through October 2006, IBD outpatients and primary care outpatients at the University of Kentucky (UK) were surveyed by trained clinicians, using chart data to augment patient response. A second sample of IBD patients from the University of Chicago was studied with a self-administered survey. Results: One hundred and seventeen IBD subjects were enrolled at UK, 125 IBD subjects were enrolled at UCH, and 100 control subjects were recruited from UK primary care clinics. The overall age-/sex-adjusted screening rate, as measured by the screening index, was significantly lower in UK IBD subjects than in UK controls (75.1% versus 83.9%, P = 0.0002). The UCH data showed a 67% overall age-/sex-adjusted screening rate. After adjusting for insurance status, the difference in screening rates was still lower for IBD patients than for controls (71% versus 78%; P = 0.022). Neither disease type nor disease control rating predicted screening rate. Conclusions: Our data suggest IBD patients do not receive preventive services at the same rate as general medical patients. Preventive care is a facet of global IBD management that deserves further study. (Inflamm Bowel Dis 2007)

Introduction: Complementary and alternative medicine (CAM) encompasses a wide variety of increasingly popular therapies not generally taught in allopathic medical schools but of apparent interest to medical trainees. However, little is known about the learners’ specific needs for improving their CAM clinical skills. Methods: Third-year medical students and internal medicine resident-physicians at the University of Kentucky were invited to participate in a voluntary questionnaire to assess CAM knowledge, skills, attitudes as well as their desired learning methods. Results: Medical students (n ¼ 22) and resident-physicians (n ¼ 39) generally hold favorable attitudes toward CAM but admit to significant knowledge deficits and do not feel adept at counseling their patients about CAM. Students indicate observation and hands-on experiences as their preferred pedagogy while residents favor textbooks, articles, and lectures to learn about CAM. Nevertheless, one resident noted, ‘‘any information in any format would be helpful as we get no teaching in this area’’. Conclusions: In our sample, learner-driven CAM education at undergraduate and graduate levels is indeed necessary and wanted. In constructing CAM education interventions, attitudes, perceived knowledge deficits, and preferred learning strategies should be considered for the trainees and thus ultimately responsive to the needs of their patients.

This journal watch is sponsored by the Alliance for Clinical Education (ACE) and continues the annual reviews of medical education articles on behalf of the Clerkship Directors in Internal Medicine...

Sexual history and HIV counseling (SHHIVC) are essential clinical skills. Our project's purpose was to evaluate a standardized patient educational intervention teaching third-year medical students SHHIVC.A four-hour standardized patient workshop was delivered to one-half of the class each of three consecutive years at one medical school. Approximately 3.5 weeks later, all students engaged in a standardized patient examination including one station assessing SHHIVC, answered an open-ended written exercise following the standardized patient encounter, and completed a written examination including sexual history and HIV-related questions.Workshop participants scored higher than non-participants on SHHIVC items on the standardized patient station (P.0001), written exam (P.0001), and open-ended written exercise after the standardized patient encounter (P = .024).Our SHHIVC curriculum was associated with students demonstrating better clinical skills on a SHHIVC standardized patient examination station and more SHHIVC knowledge on two measures of medical knowledge than students not participating in the SHHIVC educational intervention.

This journal watch is sponsored by the Alliance for Clinical Education and continues the reviews of medical education articles initiated by Jennifer Kogan on behalf of the Clerkship Directors of Internal Medicine.1 As with its predecessors,1,2 the purpose of this article is to identify and summarize medical education publications from specialty journals that are particularly salient to educators across specialties who would not usually read these journals. We are grateful to Teaching and Learning in Medicine and the Alliance for Clinical Education for giving us a forum in which we can share our education research, learn from our colleagues in other fields, and open dialogs of collaboration. The members of the Publication Committee of the Clerkship Directors of Internal Medicine reviewed the literature and prepared this review. Included are articles published in the 12 months following the last review, from September 1, 2004, through August 31, 2005. Our initial search of the Medline® database used the med...

The purpose of our study was to determine how time spent with the physician might be related to patient dissatisfaction with their waiting time. During a 2-month period, patients in our internal medicine resident continuity clinic completed a survey assessing their satisfaction with their waiting time and their estimates of their waiting time and time spent with the resident physician. For patients with long waiting times (more than 15 min in the waiting room or more than 10 min in the exam room), patient dissatisfaction with waiting time was associated with a shorter physician visit (48% were dissatisfied if the physician spent less than 15 min vs. 18% if the physician spent more than 15 min with them, p = .03). These data suggest that physicians can mediate the negative effects of long waiting times by spending more time with their patients. Future studies on patient satisfaction should consider this interaction.

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.

Inpatient internal medicine education occurs in a fragile learning environment. The authors hypothesized that when medical students are involved in teaching rounds, residents may perceive a decrease in value of attending teaching.During two summer periods, trained research assistants shadowed teaching rounds, tracking patient census and team call status, recording basic content of rounds, and delivering a survey instrument to the learners, asking them to rate the quality of the attending's teaching that day.One hundred sixty-six rounds were analyzed. Attending teaching ratings peaked when students were highly involved. In fact, high student involvement was an independent predictor of higher resident evaluation of teaching rounds (P.0001).The best teaching occurred when involvement of medical students was greatest and their involvement was not necessarily a zero-sum game. The authors conclude that attending investment in medical student education during teaching rounds benefits all members of the inpatient team.

Global surveys of residents have consistently identified stress variables as important factors in resident job performance.Determine whether an association exists between resident stress and job performance.Over a three month period, interns on our inpatient ward services were surveyed regarding their current call schedule, whether their prior night's sleep was sufficient, whether they felt pressed by other commitments, whether they spent enough time teaching medical students and whether they had completed all patient care issues on a given day. Multiple logistic regression was used to assess the association between call status, pressure and sleep adequacy with reported omissions in patient care and adequacy of teaching.In the regression analysis, ratings of high pressure and insufficient sleep but not call status independently predicted outcomes. For example, if an intern felt both pressed and tired, they were over eight times more likely to omit a patient care issue and over four times more likely to report inadequate teaching.Subjective ratings of high pressure and insufficient sleep are associated with poor job performance in medical residents.

As the use of complementary and alternative medicine (CAM) has increased in the general population, so has the interest in CAM education among medical students and medical educators. The purpose of this study is to determine the impact of a CAM workshop using standardized patients (SP) on knowledge and clinical skills of third-year medical students.A 4-hour CAM workshop was developed as part of a new curriculum for a required third-year 4-week primary care internal medicine clerkship. The CAM workshop and 3 other novel workshops were randomized for delivery to half of the rotational groups. The CAM workshop incorporates 4 SP cases representing different clinical challenges. All students in every rotation group are assigned CAM readings. At the end of the rotation, all students take a 100-item written exam (7 CAM items) and 9-station SP exam (1 CAM station) including a post-SP encounter open-ended written exercise. Scores on the written exam CAM items, CAM SP checklist, and CAM open-ended written exercise of workshop participants and nonparticipants were analyzed with simple means, standard deviations, and multiple regression approaches.The CAM workshop was delivered to 12 of the 24 rotation groups during the 2004-2005 and 2005-2006 academic years. Ninety-two students participated in the workshop, and 94 did not. Workshop participants performed significantly better than nonparticipants on the CAM-specific SP checklist items (58 vs 36.6%, P.0001), post-SP encounter written exercise (76.9 vs 63.3%, P.0001), and 7 CAM written exam items (84.8 vs 76.3%, P.0001).Students participating in a 4-hour SP workshop exhibit superior CAM knowledge as assessed by SP checklist, open-ended exercises, and multiple choice items. It appears that practice with SPs assists in acqusition and application of CAM knowledge and deferential counseling skills.

The purpose of this study was to assess the influence of resident nonclinic workload on the satisfaction of continuity clinic patients. Over a 2-month period in 2002, residents and patients were surveyed at the University of Kentucky internal medicine continuity clinic. Residents provided a self-report of their nonclinic workload as light or medium versus heavy or extremely heavy. Patient satisfaction was assessed with a 7-item, 10-point scale with items derived from commonly used patient satisfaction instruments. In 168 patient encounters, patients were significantly less satisfied with their clinic visit if they were seen by a resident who had a heavier workload. In addition, these patients gave significantly lower ratings with regard to the amount of time spent with the patient during the visit, and how well the resident listened and paid attention. Although alternative explanations exist, we propose that heavy hospital workload is associated with decreased patient satisfaction in resident continuity clinic.

Due to recent public debate and newly imposed resident work hour restrictions, we decided to investigate the relationship of resident call status to their ambulatory patients' satisfaction. Resident continuity clinic patients were asked to rate their level of satisfaction on a 10-point Likert-type scale. Using multiple regression approaches, these data were then assessed as a function of resident call status. We found that in 646 patient encounters, patient satisfaction scores were significantly less when the resident was postcall, 8.99 +/- 1.8, than when not postcall, 9.31 +/- 1.3. We herein discuss etiologies and implications of these findings for both patient care and medical education.

Objective To determine the effect of a medical school adolescent medicine workshop on knowledge and clinical skills using standardized patients. Design Randomized controlled trial. Setting The University of Kentucky College of Medicine, Lexington. Participants A total of 186 third-year medical students. Intervention Medical students assigned to the intervention group (n = 95) participated in a 4-hour adolescent medicine workshop using standardized patients to practice interviewing and counseling skills. Medical students assigned to the control group (n = 91) participated in an alternative workshop. Outcome Measures Medical student adolescent interviewing and counseling skills were assessed using adolescent standardized patient encounters during the end-of-clerkship examination and during the end of the third-year Clinical Performance Examination. Medical student knowledge was assessed at the end of the clerkship using an open-ended postencounter written exercise and the questions specific to adolescent medicine on the clerkship written examination. Results Both groups had comparable baseline characteristics. Medical students in the intervention group scored significantly higher on both measures of clinical skills, the standardized patient stations during the end-of-clerkship examination and the Clinical Performance Examination. Intervention medical students also scored significantly higher on both measures of knowledge, the open-ended postencounter written exercise and the written examination. Conclusions A brief adolescent medicine workshop using standardized patients improved medical students' knowledge and skills at the end of a 4-week clerkship, and the improvement in clinical skills persisted at the end of the third year of medical school.

Background The CD4+ T helper cell count is critical when managing persons living with HIV (PLWH) as it holds clear ramifications for disease severity and susceptibility to opportunistic infections. One would imagine, therefore, that PLWH are well aware of their own CD4 count. The purpose of this study is to examine variables related to unawareness of own CD4 count to better understand possible additional uninformed or perhaps even harmful behaviors. Methods Patients presenting at the University of Kentucky HIV Clinic were asked to complete a voluntary, IRB-approved, questionnaire regarding their physical and mental health. Data were analyzed with respect to CD4 awareness by simple means, standard deviations, and multiple regression approaches solving for demographics, HIV risk, medication adherence, and other comorbidities. Results Of the 123 surveys delivered, 102 (82.9%) were returned. Mean age was 40.6 6 9.1 (22-67). Eighty-five were men (83%) and 17 (17%) were women. There were 82 Caucasians, 15 African Americans, 3 Hispanic/Latinos, and one Asian. Sixty-four respondents (67%) are men who have sex with men (MSM), 13 (14%) report high-risk heterosexual activity (HRH), 4 (4%) have a history of intravenous drug use, 2 (2%) indicate blood exposure, and 13 (13%) do not know their risk factor. Fifty-one (50%) count depression and 29 (28.4%) anxiety as a concomitant diseases. Twenty-eight (29%) do not know their CD4 count. Mean CD4 for those reporting a number is 321. Trends and signficant independent variables in our model associated with not knowing one9s CD4 count include a higher likelihood of church attendance (p = .042) and spirituality scores (p = .14), poorer medication adherence (p = .097), higher drug use (p = .047), being a woman (p = .078), and feelings of discrimination (p = .005). There was no correlation with age, education, income, HIV risk, depression, anxiety, or other "don9t know " variables. Conclusions In this sample, nearly one-third of respondents did not know their CD4 count. A possible explanation may lie with the observed association with "faith " variables such as spirituality and church attendance. Alternatively, the highly significant positive responses regarding discrimination may belie some "avoidant " tendencies. Nevertheless, these data suggest that a subgroup of PLWH are in dire need of education or otherwise improved participation in their own disease management.

Background Despite improved biological understanding and lay education about HIV disease, a stigma persists for persons living with HIV (PLWH). Fears of contamination, assumptions of promiscuity, insurance concerns, and even condemnation by the medical profession are likely contributors to this psychological burden. Not surprisingly, social support has been inversely associated with depression, suicide, and disease outcomes. The purpose of this study is to determine the extent and characteristics of feelings of discrimination in a sample of PLWH. Methods A voluntary, IRB-approved questionnaire was offered to patients presenting to the University of Kentucky HIV clinic. In addition to demographic information, participants were asked, "Do you ever feel discriminated against? If so, how? " The anonymous responses were then analyzed with regard to offered demographic variables and classified into themes using grounded response theory. Two independent reviewers (A.R.H., D.B.) initially classified responses with disparities resolved by a third reviewer (M.J.L.). Results Of the 123 surveys delivered, 102 (82.9%) were returned. Demographic information finds: mean age 40.6 6 9.1 (22-67); 83% men; 80% Caucasian, 15% African American, 3% Hispanic, and 1% Asian; 67% are men who have sex with men (MSM), 14% indicate high-risk heterosexual activity (HRH), 4 (4%) intravenous drug use, 2% report blood exposure, and 13% do not know their HIV risk factor; 50% have depression, and 28.4% have anxiety. Eighty-eight completed the discrimination item, with 35 (40%) answering affirmatively. Major themes to emerge (examples) include societal ("third-class citizen "), institutional ("the court systems don9t understand "), ignorance ("only if people are uneducated "), medical ("nurses act weird "), interpersonal ("some are afraid to touch you "), and self-imposed feelings ("I feel like a leper "). Of the 53 negative responses, 15 (28%) suffer no discrimination because no one is aware of their disease. There were no significant correlations between demographics and feelings of discrimination. Conclusions The data suggest that feelings of discrimination indeed persist but may actually be less than previously reported. Many who do not harbor such feelings attribute this to nondisclosure. Possible explanations of these findings are both improved societal acceptance and advances in HIV treatment. Further research is needed to better understand and eradicate discrimination against PLWH.

Background As the use of complementary and alternative medicine (CAM) has increased in the general population, medical students and medical educators have responded with CAM interest groups and CAM curriculum. However, formal CAM instruction varies and is especially less structured in the southeastern US. The purpose of this study is to determine the impact of a CAM workshop (WS) using standardized patients (SP) on knowledge and clinical skills of third-year medical students. Methods A 4-hour CAM WS was developed as part of a new curriculum for a required third-year 4-week primary care internal medicine clerkship. The CAM WS and other novel WS were randomized for delivery to half of the rotational groups. The CAM WS incorporates four SP cases representing different clinical challenges (chiropractic, acupuncture, dietary supplement counseling). A faculty preceptor facilitates group discussion of sensitive approaches to the problems. Participating students are provided a 44-page CAM reference and all students are assigned CAM readings. At the end of the 4 weeks, all students take a 100-item written exam (seven CAM questions) and nine-station SP exam (one CAM station) including a post-SP encounter open-ended written exercise. Scores on the written exam CAM items, CAM SP checklist, and CAM open-ended written exercise of workshop participators and nonparticipators were analyzed with simple means, standard deviations, and multiple regression approaches controlling for USMLE Step 1 scores and preventive care SP station checklist scores. Results The CAM WS was delivered to 6 of the 12 rotation groups during the 2004-2005 academic year. Forty-eight students participated in the workshop and 49 did not. Workshop participants performed significantly better than nonparticipants on the seven CAM written exam items (5.8 6 0.73 vs 5.2 6 1.2, F = 7.7, p = .007) and the post-SP encounter written exercise (92.4 6 7.4% vs 88.3 6 8.5%, F = 6.3, p = .014). There was no signficicant difference (p = .963) between the groups on the SP-checklist. Conclusions Students participating in a 4-hour SP workshop exhibit superior CAM knowledge as assessed by open-ended and multiple-choice exercises. It appears that CAM attitudinal and deferential counseling skills are easily integrated into basic interviewing; however, practice with SPs does assist in acqusition and application of CAM knowledge.

Purpose A proposed reason for the unacceptably high rate of medical errors in today9s hospitals is that fatigued resident physicians make more mental mistakes. In part because of this concern, the ACGME has imposed duty hours restrictions on all residents. Little is known about how stress impacts patient care. We hypothesized that residents with greater stress would more frequently report suboptimal patient care. Methods For two consecutive years (2004 and 2005), research assistants surveyed residents working on our internal medicine inpatient teams following morning attending rounds. Both residents and interns were asked to complete a brief questionnaire, which included four questions to rate their current stress level (eg, this has been a stressful day, 1 = strongly disagree and 5 = strongly agree) and three questions to assess the impact of stress on their life and work (eg, indicate how fatigue has interfered with your work, 0 = does not interfere and 10 = completely interferes). Further, residents were asked if any patient care issues were not completed on that day, whether any medical errors affected a patient, and whether any of those resulted in suboptimal care. Data were analyzed using descriptive statistics and simple correlations to assess the association of stress ratings with the patient care variables. Summary A total of 271 resident surveys were returned from 163 inpatient team days. The mean stress level across all four stress statements was 2.6 6 1.1 and the mean impact of that stress was 5.2 6 2.2 across the three impact of stress on life and work statements. Overall, 21% reported that they had omitted some aspect of patient care, 20% reported a medical error affected a patient on their team, and 8% reported resultant suboptimal care. Resident stress correlated highly with medical errors affecting patient care (p = .007) and marginally with suboptimal care (p = .09). Stress impacting life and work correlated highly with omitting certain patient care duties (p = .03), medical errors affecting patient care (p = .04), and suboptimal care (p = .04). Conclusions Resident stress ratings are negatively associated with important patient care variables (omissions in patient care, medical errors, and suboptimal care). Perhaps more important than stress levels is the impact of that stress on an individual9s life. With current ACGME regulations, some have suggested that resident stress and workload will increase given similar work duties but less available time. The impact of duty hours regulations must be closely monitored in our teaching hospitals in order to ensure a high level of patient care.

Background Medical students rarely have the opportunity to learn and practice tactful history-taking and delicate counseling skills critical to adolescent health. The purpose of this study is to determine the impact of an adolescent medicine (AM) workshop (WS) using standardized patients (SP) on knowledge and skills of third-year medical students. Methods A 4-hour AM WS was developed as part of a new curriculum for a required third-year medical school 4-week primary care internal medicine clerkship and randomized for delivery to half of the rotational groups. The WS incorporates four SP cases representing different clinical challenges (sexual history, depression/suicide, risky behavior, and smoking cessation). A faculty preceptor facilitates group discussion of sensitive approaches to the problems. Participating students are also provided with a 26-page AM reference. All students in every rotation group are assigned AM readings. At the end of the 4 weeks, all students take a 100-item written exam (six AM questions) and nine-station SP exam (one AM station) including a post-SP encounter open-ended written exercise. Scores on the written exam AM questions, AM SP checklist items, and AM open-ended written exercise of workshop participants and nonparticipants were analyzed with simple means, standard deviations, and multiple regression approaches solving for a preventive medicine SP station and USMLE Step 1. Results The AM WS was delivered to 6 of the 12 rotation groups during the 2004-2005 academic year. Forty-nine students participated in the workshop and 48 did not. Workshop participants performed significantly better than nonparticipants on the AM SP checklist (90.5% 6 4.7 vs 85.5% 6 5.5, F = 22.6, p = .000) and the post-encounter written exercise (86.2% 6 4.1 vs 83.9% 6 4.1, F = 6.6, p = .011). Unadjusted for USMLE, participators performed significantly better on the six written exam AM items (4.8 6 0.9 vs 4.3 6 1.2%, F = 5.1, p = .027) and displayed a trend after adjustment (4.72 6 0.9 vs 4.31 6 1.2, F = 3.6, p = .06). Conclusions Students participating in a 4-hour SP workshop display superior AM clinical skills as assessed by a SP clinical exam, open-ended written exercise, and AM-specific items on a written examination. Simulation with SPs appears to be an ideal medium for teaching clinical skills. These findings support the theory that the unique aspects of adolescent patient care would be better taught using an interactive pedagogy.

Background Only about 20% of Americans consume the recommended proportions of fruits and vegetables and achieve the recommended level of physical activity. Also, only about 40% of patients report receiving dietary or exercise advice from their doctor. Therefore, nutrition and physical well-being (NPWB) knowledge and counseling skills should be part of the medical student curriculum. The purpose of this study is to determine the impact of a NPWB workshop (WS) using standardized patients (SP) on knowledge and clinical skills of third-year medical students. Methods A 4-hour NPWB WS was developed as part of a new curriculum for a required third-year 4-week primary care internal medicine clerkship. The NPWB WS and three other novel WS were randomized for delivery to half of the rotational groups. The NPWB WS incorporates four SP cases representing different clinical challenges (exercise prescription, diabetic dietary counseling, stress reduction strategies, and low-carbohydrate diet counseling). A faculty preceptor facilitates group discussion of sensitive approaches to the problems. Participating students are also provided a 17-page NPWB reference. All students in every rotation group are assigned NPWB readings. At the end of the 4 weeks, all students take a 100-item written exam (seven NPWB questions) and nine-station SP exam (one NPWB station) including a post-SP encounter open-ended written exercise. Scores on the written exam NPWB items, NPWB SP checklist, and NPWB open-ended written exercise of workshop participants and nonparticipants were analyzed with simple means, standard deviations, and multiple regression approaches controlling for USMLE Step 1 scores and preventive care SP station checklist scores. Results The NPWB WS was delivered to 6 of the 12 rotation groups during the 2004-2005 academic year. Forty-nine students participated in the workshop and 48 did not. Workshop participants performed significantly better than nonparticipants on the NPWB written exam items (5.7 6 1.0 vs 4.9 6 1.2, F = 13.9, p Conclusions Students participating in a 4-hour SP workshop exhibit superior NPWB knowledge as assessed by open-ended and multiple-choice questions. NPWB attitudinal and supportive counseling skills are easily integrated into basic interviewing while practice with SPs assists in acquisition of knowledge.

Background Depression, substance abuse, and alcohol abuse are known to play a significant role in chronic diseases and especially afflict persons living with HIV (PLWH). The purpose of this study is to report the prevalence of these disorders in a population of PLWH and identify predisposing correlates. Methods A voluntary, IRB-approved questionnaire was offered to patients presenting to the University of Kentucky HIV clinic. Depression was assessed with both self-reported medical history as well as the 9-item Patient Health Questionnaire Depression Scale (PHQ-9). Substance abuse was assessed with the 10-item Short Drug Abuse Screening Test (DAST-10) and 10-item Alcohol Use Disorders Identification Test (AUDIT). Self-reported demographic information was also collected. The data were analyzed through the use of simple means, standard errors, and Pearson product-moment correlations. Results Of the 123 surveys delivered, 102 (82.9%) were returned. Demographic information finds: mean age 40.6 6 9.1 (22-67); 83% men; 80% Caucasian, 15% African American, 3% Hispanic, and 1% Asian; 67% are men who have sex with men (MSM), 14% indicate high-risk heterosexual activity (HRH), 4 (4%) intravenous drug use, 2% report blood exposure, and 13% do not know their HIV risk factor; 50% have depression, and 28.4% have anxiety. The proportion of worrisome scores on these measures were 57.8% (PHQ $ 5 indicating depression), 11.8% (DAST $ 3), and 9.3% (AUDIT $ 8). Individual PHQ item analysis finds that 66.33% feel depressed, 72.92% have difficulty sleeping, 68.13% have poor appetite, and 24.5% are suicidal. Regarding drug abuse, 43.43% have used drugs for nonmedical reasons, 11.22% have neglected their family because of drugs, and 13.27% are unable to stop using drugs. Most (91.67%) do not consume more than 1-2 drinks per week, but 26.04% report some binge-drinking and 11.34% have been told to cut down. Significant correlations include self-reported depression and anxiety with PHQ scores (r = .473, p Conclusions The data suggest that depression is quite rampant in this population. Alcohol and drug abuse do not appear disproportionate; however, the small but significant binge-drinking and inability to stop using drugs could conceivably affect their disease outcomes. Mental health disorders represent serious, common, but identifiable and treatable comorbid disease in an already vulnerable population.

Background Geriatric patients account for about 40% of internists9 office visits and there is an expected 115% increase for geriatric services by 2030. Older patients tend to have multiple condidtions, polypharmacy, and altered physiology. Therefore, geriatric medicine (GM) should be emphasized in the medical student curriculum. The purpose of this study is to determine the impact of a GM workshop (WS) using standardized patients (SP) on knowledge and clinical skills of third-year medical students. Methods A 4-hour GM WS was developed as part of a new curriculum for a required third-year 4-week primary care internal medicine clerkship. The GM WS and three other novel WS were randomized for delivery to half of the rotational groups. The GM WS incorporates four SP cases representing different clinical challenges (dementia, depression, incontinence, and syncope). A faculty preceptor facilitates group discussion of sensitive approaches to the problems. Participating students are also provided with a 11-page GM reference. All students in every rotation group are assigned GM readings. At the end of the 4 weeks, all students take a 100-item written exam (seven GM questions) and nine-station SP exam (one GM station) including a post-SP encounter open-ended written exercise. Scores on the written exam GM items, GM SP checklist, and GM open-ended written exercise of workshop participants and nonparticipants were analyzed with simple means, standard deviations, and multiple regression approaches controlling for USMLE Step 1 scores and preventive care SP station checklist scores. Results The GM WS was delivered to 6 of the 12 rotation groups during the 2004-2005 academic year. Forty-eight students participated in the workshop and 49 did not. Workshop participants performed significantly better than nonparticipants on the GM SP checklist (86.5 6 8.7% vs 79.7 6 10.0%, F = 13, p = .001) and showed positive trends for the post-encounter written exercise (78.9 6 6.9% vs 75.5 6 12.9%, F = 2.6, p = .112) and the seven written exam GM items (5.31 6 0.74 vs 4.98 6 0.98, F = 3.54, p = .063). Conclusions Students participating in a 4-hour SP workshop display superior GM clinical skills as assessed by a SP clinical exam and there is a trend toward knowledge gain on a written examination. These findings lend additonal support to the theory that there are unique aspects to caring for older patients, which might be better taught using an interactive pedagogy.

Background Intimate partner violence (IPV) is a public health problem of unknown magnitude. Several studies have been performed to examine the prevalence of IPV in the context of persons living with HIV (PLWH) and have found socioeconomic, ethnic, and gender implications. The purpose of this study is to examine the prevalence of IPV among PLWH in different risk factor subgroups, eg, men who have sex with men (MSM) and PLWH related to high-risk heterosexual behavior (HRH). Methods Patients presenting at the University of Kentucky HIV Clinic were asked to complete a voluntary, IRB-approved questionnaire regarding their physical and mental health. Specifically, participants were asked whether or not theye had experienced IPV in the past year. Affirmative responses were analyzed with respect to HIV risk category by simple means, standard deviations, and multiple regression approaches solving for gender, income, and education. Results Of the 123 surveys delivered, 102 (82.9%) were returned. Sixty-four respondents (67%) recorded MSM as their risk, 13 (14%) indicated HRH, and 19 (18.6%) were nonsexual risk factors or did not know. Only one person in the latter group (5.5%) reported IPV. Of those in the MSM subgroup, 11.1 6 32% reported experiencing IPV in the last year vs 36.4 6 50% in the HRH subgroup (p = .04). Gender, income, and education were not signficant predictors in several regression models. Conclusions These data suggest that IPV among PLWH is significantly more common in the HRH subgroup than the MSM subgroup. Previous studies have found the risk of violence in a woman9s lifetime to be 20-30% and violence prevalence in MSM relationships of about 40%. This study is limited by the relatively low proportion of HRH in the sample population as well as being conducted at a single institution. Nevertheless, when compared to national data, PLWH exposed through HRH have a very high rate of IPV even when controlling for gender, income, and education. Further research should be conducted on this subgroup to determine other aspects of this vulnerable population that may be neglected or overlooked.

Purpose Every physician has experienced the emotional drain of a difficult patient encounter. Do these draining encounters adversely affect patients seen later in the day? The purpose of this study was to determine if an unsatisfying patient encounter was likely to result in a less satisfying encounter for the subsequent patient. Methods During two summer periods, a convenience sample of resident continuity clinic patients was surveyed regarding their satisfaction with the clinic visit. Patient satisfaction was assessed with seven items measured on a 10-point scale (1 = strongly disagree, 10 = strongly agree). Given that patient satisfaction, as seen in other patient satisfaction studies, is generally very high, a satisfying encounter was defined as one with 109s on all seven items while a less than perfectly satisfying encounter was defined as one with any score less than 10. This study focused on the satisfaction of the patient seen following a less satisfied patient. Results One hundred fifty patient encounters were available for analysis. In general, 58% of the patients were satisfied with their visit. However, only 30% were satisfied if they were seen after a less satisfied patient, (p Conclusions After an unsatisfactory patient encounter, the next patient is more likely to be dissatisfied with their visit. Further research should explore how our interactions with patients influence other patient interactions on a given day.

Purpose It has long been known that the gender of the physician and of the patient can impact variables of medical communication. In this experiment, we study the effect of both student and standardized patient (SP) gender as it relates to the sexual history taking and HIV risk reduction counseling. Methods At the University of Kentucky College of Medicine, the third-year class must adequately complete a 13-station standardized patient clinical examination to matriculate into the fourth year. Each station is graded by a checklist of salient items completed by the SP. One of the stations, the HIV risk reduction counseling case, was developed to be portrayed by both a male and female SP and contained gender-specific items on the checklist. There were eighty total items on the female checklist and sixty-nine total on the male checklist. The male checklist contained eleven and the female seventeen sexual history items and both contained ten HIV counseling items. One-half of all the students interviewed a man at risk for HIV and the other students encountered a woman. Every student had an equal chance to encounter either gender. A gender-neutral anxiety case was used as the control. Multiple regression approaches solving for measures of prior clinical performance and using the general linear model were used to analyze the data with SAS. Results Ninety-seven students completed the CPX. Forty-nine encountered a female SP and forty-eight a male SP. There were twenty-two women in both groups. The performance of the female students was superior to that of the men in regards to both the elements of the sexual history taking and the HIV risk reduction counseling (62.8 ± 13.7 vs. 56.4 ± 15.2, p Conclusions Female medical students score better than their male counterparts on sensitive elements of a standardized patient encounter, sexual history taking, and HIV risk reduction counseling. In fact, even when there are more items to ask, i.e., in an encounter with a female SP, the female students continue to excel. Limitations to our study include single institution and study of only one SP case. However, despite these limitations, our findings suggest both areas of future focus for clinical medical education and possible gender influences in actual patient-physician encounters.

Purpose To assess the need for complementary and alternative medicine (CAM) instruction at the University of Kentucky College of Medicine (UKCOM) to assist in the development of a planned educational intervention. Methods An IRB-approved written questionnaire was delivered to the UKCOM Class of 2006 and the internal medicine resident-physicians at a scheduled conference. Participants denoted demographic information, personal use of CAM, as well as rated their attitudes toward CAM modalities and CAM instruction needs on a 5-point Likert-type scale, and completed a 10-item multiple choice quiz about common CAM modalities. Data analysis including descriptive, correlational, t-tests, reliability, and validity were performed using SPSS. Results Thirty-nine (78%) residents and twenty-nine (97%) students who were approached completed the survey. Other than age, there were no significant differences in sociodemographic backgrounds between the two groups (p > .05). Both students and residents equally hold favorable attitudes toward CAM and are interested in learning more about CAM modalities especially counseling (72 ± 45), yoga (43 ± 50), meditation (41 ± 50), and relaxation (41 ± 50). Perceived knowledge deficits were significantly greater in the resident group compared to the students regarding acupuncture (77 ± 43 vs. 50 ± 52, p = .032), hypnotherapy (85 ± 37 vs 59 ± 50, p = .026), osteopathy (82 ± 39 vs 55 ± 51, p = .021), and chiropractic (51 ± 51 vs 23 ± 43, p = .03). Both groups performed poorly on the knowledge assessment component with an overall mean score of 5.6 ± 1.7 (5.6 ± 1.9 vs 5.5 ± 1.3, p = .86). The students displayed a greater desire to learn more about CAM modalities, especially hypnotherapy (100 ± 0 vs 69 ± 47, p = .003). Regarding CAM instruction needs, the students identified observation of CAM practitioners significantly more desirable than residents (4.1 ± .89 vs. 3.3 ± 1.1, p = .002). Conclusions CAM education is valued by both cohorts in this study population. However, the degree to which knowledge deficits are admitted, education is desired, and the means by which their needs should be met are variable. These findings might reflect motivation and idealism by the students or cynicism by the residents in regards to time constraints and practicality of educational interventions at their level. Limitations to our study include single institution and variability of previous CAM instruction. We attempted to solve for sociodemographic and previous CAM use biases. In light of these findings, those developing CAM educational interventions should take into account potential learner need variation.

Purpose Few studies have examined the content of teaching rounds on general internal medicine ward services. Even less is known about what makes for effective attending teaching rounds with regard to resident and medical student education. We hypothesized that both students and residents would feel that rounds were educational if they were more actively involved. Methods Over a four month period, trained research assistants (second year medical students) observed attending rounds at our university hospital. The research assistants coded the two most dominant activities occurring within each 5-minute interval during rounds with respect to content and involvement. Activities on rounds were conceptualized as involving either teaching, patient care, administrative tasks or dead time. Involvement was coded as to the participation of individual team members: attending physician, upper level resident, interns and students. For the purpose of analysis, each team member9s involvement was calculated as the percentage of the total rounding time that they were judged to be involved in the discussions. After rounds, the research assistants rated the rounds with regards to teaching quality (1 = poor, 10 = excellent) and the perceived student/resident involvement (1 = not involved, 10 = very involved). Results Overall, 96 different attending rounds were observed. The teaching quality of rounds was judged to be above average with a mean rating of 6.2 ± 2.2. Overall residents were judged to be more involved than students, 8.4 ± 1.7 versus 5.1 ± 2.6. Likewise, examining the percentage of rounds involving different team members, attending physicians were the most involved (accounting for 72% of the interactions on rounds), followed by residents (41%), interns (37%) and finally students (23%). The overall teaching quality as judged by the research assistants was associated with higher rating of perceived student involvement (r = .37, p = .0005) but not with the perception of resident involvement (r = .12, p = .24). Examining the percentage of rounding time involving different team members, research assistants judged rounds to be of higher teaching quality when the attending physicians were less involved (r = -.25, p = .02). Conclusions The majority of teaching rounds are centered on the attending physician with medical students having the lowest involvement of all team members. However, the teaching that occurs on attending rounds is judged to be of higher quality when medical students are more involved and attending physicians are less involved.

Purpose The attending is considered the clinical teacher on traditional general internal medicine ward services, with contributions from various learners, including residents, interns and medical students. Few studies have reported the quantity of time devoted to patient care, separate teaching sessions and administrative work during attending rounds. We explored the relative contribution of these components during the daily attending rounds on a typical university hospital9s general medicine inpatient service. Methods Over a four month period, trained research assistants (second year medical students) observed attending rounds at our university hospital. The research assistants coded the two most predominant activities for 90 minutes of each session in 5-minute intervals with respect to content and involvement of the teams9 members quality of the teaching and presence of the patient during the discussions. The activity on rounds was conceptualized as patient care, teaching, or administrative work. The discussions on rounds were conceptualized as open discussions involving most members of the team, interactions between two team members (dyad), lecture by a single individual or none of the three (“dead” time). After rounds, the research assistants rated the rounds with regards to involvement of each of the key team members (1 = not involved, 10 = very involved). Results Overall, 96 distinct daily rounds sessions were evaluated. Patient care was the focus of the discussion of the majority of the time spent, ranging from 55% to 83% of total time spent on attending rounds (median = 66%). Separate time allocated to teaching comprised 3-11% of the rounds (median = 6%), while 0-9% of time was spent on administrative work (median = 3%). Of interest, the median time spent at the bedside with the patient present was 28% (range 1-40%). In our sample, open discussions dominated rounding activities, while solo and dyad discussions were noted less frequently. “Dead” time was minimal. The attending was involved in teaching discussions most frequently throughout rounds, with diminishing amounts of involvement of the resident, intern and student Conclusions The largest majority of time spent teaching on attending rounds is in the context of patient care (i.e. - bedside rounds). Only 6% of time teaching is spent in separate sessions and even less time was spent on administrative work. While most of the teaching is performed at the bedside, only 28% is with the patient present during the discussion. The attending is the dominant teacher at the bedside in our institution, using open discussion more frequently than solo or dyad discussions.

Purpose To understand if greater team patient census is associated with differences in how teaching rounds are conducted, in terms of time with patients, content of rounds, persons involved and the nature of discussions. Methods Over three months of a summer period, trained medical student research assistants (RAs) shadowed teaching rounds on our general medical inpatient services. Teams generally consist of an attending physician, a supervising resident, two first year residents (interns) and/or fourth-year medical students (acting interns), and two third year medical students. Teaching rounds occur most mornings, with the entire team going to the patient9s room, presentation of the patient by the student or intern generally outside the patient9s room, with the entire team then going into the patient9s room for interaction with the patient. The RAs coded teaching rounds in 21/2 minute increments as to content (patient care, other teaching (i.e. mini-lectures, etc.) and administration), persons involved (attending, resident, interns, students, patient), and nature of discussions (open discussions with most members of the team, dyad interactions, lectures/presentations by a single individual, or dead time, such as walking). In addition, team patient census was collected and noted each day. Analysis was with Pearson9s correlations. Results Data were available for 96 teaching rounds. The mean patient census was 8.2, SD 2.7, range 2-14. Time on rounds was conducted in an open group fashion 44% of the time, 32% time in dyad fashion, 9% a solo individual, and 14% dead or not coded. Attendings were involved in the interactions 72% of the time, residents 41%, interns 37%, and students 23%. Greater patient census was associated with greater time with patients (r = .44, p Conclusion The nature of teaching rounds changes with greater patient census. More time is spent with patients, but at the expense of attendings and residents dominating rounds, at the expense of the interns and students. Future studies should investigate how patient census influences teaching quality, both for students and for residents.