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Author(s): Brown, Alisha Emily Cutler; Jauregui, Joshua; Ilgen, Jonathan S.; Riddell, Jeff; Schaad, Douglas; Strote, Jared; Shandro, Jamie | Abstract: Introduction: Social media is a novel medium to host reflective writing (RW) essays, yet its impact on depth of students’ reflection is unknown. Shifting reflection on to social platforms offers opportunities for students to engage with their community, yet may leave them feeling vulnerable and less willing to reflect deeply. Using sociomateriality as a conceptual framework, we aimed to compare the depth of reflection in RW samples submitted by medical students in a traditional private essay format to those posted on a secure social media platform.Methods: Fourth-year medical students submitted a RW essay as part of their emergency medicine clerkship, either in a private essay format (academic year [AY] 2015) or onto a closed, password-protected social media website (AY 2016). Five raters used the Reflection Evaluation for Learners’ Enhanced Competencies Tool (REFLECT) to score 122 de-identified RW samples (55 private, 67 social media). Average scores on two platforms were compared. Students were also surveyed regarding their comfort with the social media experience.Results: There were no differences in average composite REFLECT scores between the private essay (14.1, 95% confidence interval [CI], 12.0-16.2) and social media (13.7 95% CI, 11.4-16.0) submission formats (t [1,120] = 0.94, p = 0.35). Of the 73% of students who responded to the survey, 72% reported feeling comfortable sharing their personal reflections with peers, and 84% felt comfortable commenting on peers’ writing.Conclusion: Students generally felt comfortable using social media for shared reflection. The depth of reflection in RW essays was similar between the private and social media submission formats.

Background Communication failures in healthcare teams are associated with medical errors and negative health outcomes. These findings have increased emphasis on training future health professionals to work effectively within teams. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) communication training model, widely employed to train healthcare teams, has been less commonly used to train student interprofessional teams. The present study reports the effectiveness of a simulation-based interprofessional TeamSTEPPS training in impacting student attitudes, knowledge and skills around interprofessional communication. Methods Three hundred and six fourth-year medical, third-year nursing, second-year pharmacy and second-year physician assistant students took part in a 4 h training that included a 1 h TeamSTEPPS didactic session and three 1 h team simulation and feedback sessions. Students worked in groups balanced by a professional programme in a self-selected focal area (adult acute, paediatric, obstetrics). Preassessments and postassessments were used for examining attitudes, beliefs and reported opportunities to observe or participate in team communication behaviours. Results One hundred and forty-nine students (48.7%) completed the preassessments and postassessments. Significant differences were found for attitudes toward team communication (p Conclusions Effective team communication is important in patient safety. We demonstrate positive attitudinal and knowledge effects in a large-scale interprofessional TeamSTEPPS-based training involving four student professions.

This article illustrates the administrative structure that has evolved to support a multistate longitudinal inte- grated clinical clerkship (LICC) experience. In 1996 the University of Washington School of Medicine created the WWAMI Rural Integrated Training Experience (WRITE), a five-month rural continuity based LICC experience. WRITE students spend five months in a rural immersion experience with a primary care preceptor. During this time students form continuity based relationships with patients and preceptors, which allows students to develop skills and knowledge re- quired to treat the broad range of medical, surgical, and psychosocial problems found in rural communities. Administration of 21 rural sites across five states is based on a strong partnership between rural practice sites, regional clinical deans'offices, and the departments and dean's office in an academic medical center.We explore the key aspects of the multi-layered administration that has evolved to support the WRITE program. A review of the year-long calendar of the WRITE program illustrates the complexity, detail and components necessary for the administration of this successful program.Rural LICC experiences like WRITE offer a useful approach to meeting rural physician workforce needs. A brief review of the WRITE outcome data will be explored. Administration of a multistate LICC experience requires synchroni- zation of many components, especially a strong regional administrative presence that connects the rural practice sites with the academic medical center.

Studies of minimally invasive surgery (MIS) approaches to TKA have shown decreased postoperative pain, earlier return to function, and shorter lengths of stay in the hospital. However, it is unclear whether these differences translate into decreased costs or charges associated with care.We asked whether a minimally invasive approach to TKA is associated with lower inpatient charges and direct inpatient costs than the traditional approach.We retrospectively reviewed one high-volume arthroplasty surgeon's first 100 minimally invasive TKAs with the last 50 traditional TKAs with respect to all perioperative inpatient medical and billing records. Total charges minus implants (which were excluded across groups), total direct costs, and individual cost centers were analyzed.The mean nonimplant total charge was less for patients receiving a minimally invasive TKA than a traditional TKA ($13,505 versus $14,552). With the numbers available, there was a trend for lower mean direct cost for minimally invasive TKA ($6156) versus traditional TKA ($6410).The total inpatient charges associated with a minimally invasive TKA were less than those associated with a traditional TKA; however, the magnitude of the difference (7.2%) was modest, and there was no reduction in direct hospital costs. Other studies will need to determine whether any economic benefits associated with minimally invasive TKA accrue after discharge. The decision regarding whether to perform minimally invasive TKA should be made on clinical grounds, as the medical-economic case on the inpatient side is not compelling.

Most trainees in combined pulmonary and critical care medicine fellowship programs complete in-service training examinations (ITEs) that test knowledge in both disciplines. Whether ITE scores predict performance on the American Board of Internal Medicine Pulmonary Disease Certification Examination and Critical Care Medicine Certification Examination is unknown.To determine whether pulmonary and critical care medicine ITE scores predict performance on subspecialty board certification examinations independently of trainee demographics, program director competency ratings, fellowship program characteristics, and prior medical knowledge assessments.First- and second-year fellows who were enrolled in the study between 2008 and 2012 completed a questionnaire encompassing demographics and fellowship training characteristics. These data and ITE scores were matched to fellows' subsequent scores on subspecialty certification examinations, program director ratings, and previous scores on their American Board of Internal Medicine Internal Medicine Certification Examination. Multiple linear regression and logistic regression were used to identify independent predictors of subspecialty certification examination scores and likelihood of passing the examinations, respectively.Of eligible fellows, 82.4% enrolled in the study. The ITE score for second-year fellows was matched to their certification examination scores, which yielded 1,484 physicians for pulmonary disease and 1,331 for critical care medicine. Second-year fellows' ITE scores (β = 0.24, P0.001) and Internal Medicine Certification Examination scores (β = 0.49, P0.001) were the strongest predictors of Pulmonary Disease Certification Examination scores, and were the only significant predictors of passing the examination (ITE odds ratio, 1.12 [95% confidence interval, 1.07-1.16]; Internal Medicine Certification Examination odds ratio, 1.01 [95% confidence interval, 1.01-1.02]). Similar results were obtained for predicting Critical Care Medicine Certification Examination scores and for passing the examination. The predictive value of ITE scores among first-year fellows on the subspecialty certification examinations was comparable to second-year fellows' ITE scores.The Pulmonary and Critical Care Medicine ITE score is an independent, and stronger, predictor of subspecialty certification examination performance than fellow demographics, program director competency ratings, and fellowship characteristics. These findings support the use of the ITE to identify the learning needs of fellows as they work toward subspecialty board certification.

Background: There is disagreement about whether so-called minimally invasive approaches result in faster recovery following total knee arthroplasty. It is also unknown whether patients are exposed to excess risk during the surgeon's learning curve. We hypothesized that a minimally invasive quadriceps-sparing approach to total knee arthroplasty would allow earlier clinical recovery but would require longer operative times and compromise component alignment during the learning period compared with a traditional medial parapatellar approach. Methods: The first 100 minimally invasive total knee arthroplasties done by a single high-volume arthroplasty surgeon were compared with his previous fifty procedures performed through a medial parapatellar approach, with respect to operative times, implant alignment, and clinical outcomes. Radiographic end points and operative times for the minimally invasive group were evaluated against increasing surgical experience, in order to characterize the learning curve. Results: Overall, the minimally invasive approach took significantly longer to perform, on the average, than a medial parapatellar approach (86.3 and 78.9 minutes, respectively; p = 0.01); this was the result of especially long operative times in the first twenty-five patients in the minimally invasive group (mean, 102.5 minutes). After the first twenty-five minimally invasive operations, no significant difference in the operative times was detected between the groups. The first twenty-five minimally invasive procedures had significantly less patellar resection accuracy (p < 0.001) and significantly more patellar tilt than the last twenty-five (p = 0.006). Other end points for implant alignment, including the frequency of radiographic outliers, were not different between the minimally invasive and traditional groups. The patients who had the minimally invasive approach demonstrated significantly better clinical outcomes with respect to the length of hospital stay (p < 0.0001), need for inpatient rehabilitation after discharge (p < 0.001), narcotic usage at two and six weeks postoperatively (p = 0.001 and p = 0.01, respectively), and the need for assistive devices to walk at two weeks postoperatively (p = 0.025). Conclusions: A quadriceps-sparing minimally invasive approach seems to facilitate recovery, but a substantial learning curve (fifty procedures in the hands of a high-volume arthroplasty surgeon) may be required. If this experience is typical, the learning curve may be unacceptably long for a low-volume arthroplasty surgeon. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Background: Prior studies implying associations between receipt of commercial funding and positive (significant and/or pro-industry) research outcomes have analyzed only published papers, which is an insufficiently robust approach for assessing publication bias. In this study, we tested the following hypotheses regarding orthopaedic manuscripts submitted for review: (1) nonscientific variables, including receipt of commercial funding, affect the likelihood that a peer-reviewed submission will conclude with a report of a positive study outcome, and (2) positive outcomes and other, nonscientific variables are associated with acceptance for publication. Methods: All manuscripts about hip or knee arthroplasty that were submitted to The Journal of Bone and Joint Surgery, American Volume, over seventeen months were evaluated to determine the study design, quality, and outcome. Analyses were carried out to identify associations between scientific factors (sample size, study quality, and level of evidence) and study outcome as well as between non-scientific factors (funding source and country of origin) and study outcome. Analyses were also performed to determine whether outcome, scientific factors, or nonscientific variables were associated with acceptance for publication. Results: Two hundred and nine manuscripts were reviewed. Commercial funding was not found to be associated with a positive study outcome (p = 0.668). Studies with a positive outcome were no more likely to be published than were those with a negative outcome (p = 0.410). Studies with a negative outcome were of higher quality (p = 0.003) and included larger sample sizes (p = 0.05). Commercially funded (p = 0.027) and United States-based (p = 0.020) studies were more likely to be published, even though those studies were not associated with higher quality, larger sample sizes, or lower levels of evidence (p = 0.24 to 0.79). Conclusions: Commercially funded studies submitted for review were not more likely to conclude with a positive outcome than were nonfunded studies, and studies with a positive outcome were no more likely to be published than were studies with a negative outcome. These findings contradict those of most previous analyses of published (rather than submitted) research. Commercial funding and the country of origin predict publication following peer review beyond what would be expected on the basis of study quality. Studies with a negative outcome, although seemingly superior in quality, fared no better than studies with a positive outcome in the peer-review process; this may result in inflation of apparent treatment effects when the published literature is subjected to meta-analysis.

Ansab Khwaja, Douglas C Schaad, Richard W Arnold University of Washington School of Medicine, Seattle, WA, USA Background and objectives: There is a shortfall in the primary care workforce, and an effort is needed in learning more about what motivates students to work as generalists. There is enthusiasm about service as a potential motivator. The objective is to determine whether there is an association between high participation in service and selection of a primary care residency. Methods: This is a retrospective cohort analysis. The service award was used to delineate two groups, recipients and non-recipients, with the recipients considered high service participators. This was associated with residency match data using test of proportions to examine relationships between service and selection of a primary care residency and other secondary factors. Results: Of award recipients, 57.3% matched in primary care, compared to 52.8%, though this did not reach statistical significance. Service was linked with induction into Alpha Omega Alpha honor society (23.3% versus 14.6%) and induction into the Gold Humanism Honor Society (22.6%. versus 10.4%), with statistical significance. Conclusion: This was an unsuccessful attempt to find a link between service and a primary care career choice, though there is a trend in the direction. The association with induction into the humanism honor society suggests that service is linked with development and/or retention of positively viewed qualities in medical students. Keywords: primary care, community service, medical education

Background: Although most musculoskeletal illness is managed by primary care providers, and not by surgeons, evidence suggests that primary care physicians may receive inadequate training in musculoskeletal medicine. We evaluated the musculoskeletal knowledge and self-perceived confidence of fully trained, practicing academic primary care physicians and tested the following hypotheses: (1) a relationship exists between a provider's musculoskeletal knowledge and self-perceived confidence, (2) demographic variables are associated with differences in the knowledge-confidence relationship, and (3) specific education or training affects a provider's musculoskeletal knowledge and clinical confidence. Methods: An examination of basic musculoskeletal knowledge and a 10-point Likert scale assessing self-perceived confidence were administered to family practice, internal medicine, and pediatric faculty at a large, regional, academic primary care institution serving both rural and urban populations across a five-state region. Subspecialty physicians were excluded. Individual examination scores and self-reported confidence scores were correlated and compared with demographic variables. Results: One hundred and five physicians participated. Ninety-two physicians adequately completed the musculo-skeletal knowledge examination. Fifty-nine (64%) of the ninety-two physicians scored

Context: The physician assistant profession has been moving toward requiring master ' s degrees for new practitioners, but some argue this could change the face of the discipline. Purpose: To see if there is an association between physician assistants ' academic degrees and practice in primary care, in rural areas, and with the medically underserved. Methods: Surveys were sent to 880 graduates of the fi rst 32 University of Washington physician assistant classes through 2000. Respondents noted their academic degree at program entry and the highest degree attained at any time up to the time of survey. Relationships between practice characteristics and academic degree levels were tested by unadjusted odds ratios and logistic regression after controlling for year of graduation and sex. Results: Of the 478 respondents, 54% worked in primary care, about 30% practiced in nonmetropolitan communities, and 42% reported providing care for the medically underserved. Respondents with no degree (33% of total at entry, 24% at survey) were signifi cantly more likely than degree holders to work in primary care and nonmetropolitan areas. Respondents with no degree at program entry were signifi cantly more likely, and those with no degree at the time of the survey were marginally more likely, to self- report work with the medically underserved. Conclusion: Respondents with no academic degree are signifi cantly more likely to demonstrate a commitment to primary, rural, and underserved health care. These fi ndings may inform the national debate about the impact of required advanced degrees on the practice patterns of nonphysician providers. Report, the American Academy of Physician Assistants noted that 61,891 PAs were eligible for practice, and when surveyed, 19% of respondents were working in nonmetropolitan counties and 8% in federally qualifi ed health centers or community health facilities. 1 The

Many complex new procedures involve a learning curve, and patients treated by individuals who are new to a procedure may have more complications than those treated by a practitioner who has performed the intervention more frequently. Still, at some point on the learning curve, each individual must decide that he or she is qualified to perform a procedure, presumably on the basis of his or her level of confidence, background, education, and skill. To evaluate the interrelationship of these factors, we designed a study in which we assessed the performance of a simulated knee joint injection.Ninety-three practitioners attending a continuing medical education session on knee injection were randomized to receive skills instruction through the use of a printed manual, a video, or hands-on instruction; each performed one injection before and after instruction. The participants completed pre-instruction and post-instruction questionnaires gauging confidence and also provided self-assessments of their performances of injections before and after instruction. Self-assessments were compared with objective performance standards measured by custom-designed knee models with electronic sensors that detected correct needle placement.Before instruction, the participants' confidence was significantly but inversely related to competent performance (r = -0.253, p = 0.02); that is, greater confidence correlated with poorer performance. Both men and physician-practitioners displayed higher pre-instruction confidence (p0.01), which was not correlated with better performance. After instruction, performance improved significantly in all three training groups (p0.001), with no significant differences in efficacy detected among the three groups (p = 0.99). After instruction, confidence correlated with objective competence in all groups (r = 0.24, p = 0.04); however, this correlation was weaker than the correlation between the participants' confidence and their self-assessment of performance (r = 0.72, p = 0.001).Even low-intensity forms of instruction improve individuals' confidence, competence, and self-assessment of their skill in performing the fairly straightforward psychomotor task of simulated knee injection. However, men and physicians disproportionately overestimated their skills both before and after training, a finding that worsened as confidence increased. The inverse relationship between confidence and competence that we observed before the educational intervention as well as the demographic differences that we noted should raise questions about how complex new procedures should be introduced and when self-trained practitioners should begin to perform them.

We conducted a review of websites in oral health to identify content areas of our target interest and design features that support content and interface design. An interprofessional team evaluated fifty-six oral health websites originating from nongovernmental organizations (NGOs) and associations (28.6 percent), regional/state agencies (21.4 percent), federal government (19.6 percent), academia (19.6 percent), and commercial (10.7 percent) sources. A fifty-two item evaluation instrument covered content and web design features, including interface design, site context, use of visual resources, procedural skills, and assessment. Commercial sites incorporated the highest number of content areas (58.3 percent) and web design features (47.1 percent). While the majority of the reviewed sites covered content areas in anticipatory guidance, caries, and fluorides, materials in risk assessment, oral screening, cultural issues, and dental/medical interface were lacking. Many sites incorporated features to help users navigate the content and understand the context of the sites. Our review highlights a major gap in the use of visual resources for posting didactic information, demonstrating procedural skills, and assessing user knowledge. Finally, we recommend web design principles to improve online interactions with visual resources.

The Institute for International Medical Education has published "Global Minimum Essential Requirements (GMERs) in Medical Education."This study examined attitudes of a sample of Chinese medical students toward the GMERs.Matriculating and graduating West China School of Medicine Sichuan University medical students were administered parallel surveys during the 2001 to 2002 academic years.Both cohorts produced similar response profiles. The majority in both groups rated the 7 GMER domains as either important or very important for their medical education. Matriculating students rated professional values, attitudes, behavior, and ethics as most important, whereas graduating students valued clinical skills highest. Population health and health systems received the lowest importance ratings from both groups. Please note that this study was conducted before the SARS outbreak. As a result of the SARS experience, attitudes toward population health and health systems might have changed.Although medical students ascribe importance to the GMERs, efforts are needed to increase the perceived importance of the population health and health systems domain.

Providing oral health care to rural populations in the United States is a major challenge. Lack of community water fluoridation, dental workforce shortages, and geographical barriers all aggravate oral health and access problems in the largely rural Northwest. Children from low-income and minority families and children with special needs are at particular risk. Family-centered disease prevention strategies are needed to reduce oral health disparities in children. Oral health promotion can take place in a primary care practitioner9s office, but medical providers often lack relevant training. In this project, dental, medical, and educational faculty at a large academic health center partnered to provide evidence-based, culturally competent pediatric oral health training to family medicine residents in five community-based training programs. The curriculum targets children birth to five years and covers dental development, the caries process, dental emergencies, and oral health in children with special needs. Outcome measures include changes in knowledge, attitudes, and self-efficacy; preliminary results are presented. The program also partnered with local dentists to ensure a referral network for children with identified disease at the family medicine training sites. Pediatric dentistry residents assisted in didactic and hands-on training of family medicine residents. Future topics for oral health training of family physicians are suggested.

Computing and biomedical informatics technologies are providing almost instantaneous access to vast amounts of possibly relevant information. Although students are entering medical school with increasingly sophisticated basic technological skills, medical educators must determine what curricular enhancements are needed to prepare learners for the world of electronic information.The purpose was to examine opinions of academic affairs and informatics administrators, curriculum deans and recently matriculated medical students about prematriculation competence and medical education learning expectations.Two surveys were administered: an Information Literacy Survey for curriculum/informatics deans and a Computing Skills Survey for entering medical students.Results highlight differences of opinion about entering competencies. They also indicate that medical school administrators believe that most basic information skills fall within the domain of undergraduate medical education.Further investigations are needed to determine precise entry-level skills and whether information literacy will increase as a result of rising levels of technical competence.

Background: Direct observation with structured criteria for performance is the most reliable and valid method of assessing technical skill during operative procedures. We developed such a system to evaluate technical performance during a laparoscopic cholecystectomy. The reliability and validity of the system were tested by analyzing the correlation among three observers in a multicenter study and comparing performance with years of surgical experience. Study Design: Thirty consecutive cases of laparoscopic cholecystectomy were recorded on videotape, 10 from each of 3 institutions. Independent scores were generated by three observers examining each of the videotapes, providing a total of 90 scores. Points were awarded for successful completion of each of 23 different steps required to perform a laparoscopic cholecystectomy. Error points were tabulated based on the frequency and relative severity of each of 21 potential technical mistakes during the operation. The final score was assumed to be a relative measure of technical skill and was derived by subtracting error points from points awarded for completion of each step of the procedure. Pearson correlation coefficients were used to assess agreement among examiners and correlation with year of surgical experience. Results: Agreement in final scores among the three observers was excellent (r = 0.74–0.96) despite the fact that one observer assigned significantly fewer error points. Correlation between year of experience and two-handed technique scoring was good (r = 0.5, p=0.057), but the correlation between experience and one-handed technique scores was poor (r = 0.02). Conclusions: The technical skills required to perform laparoscopic cholecystectomy can reliably be measured using this tool. This method can be used to track the learning curve of surgeons in training, evaluate the efficacy of alternative training tools, and provide a means of self-assessment for the trainee.

PURPOSE To report the specialty and rural/urban distribution a mean of 19 years after graduation for a cohort of students from a family physician curricular pathway. METHOD Specialty and location information for medical students who had entered the University of Washington between 1968 and 1973 was obtained from the 1994 Physician Masterfile of the American Medical Association. RESULTS Of the 239 family physician pathway graduates, 173 (72%) had intended family practice at graduation, and 136 (57%) were family physicians two decades later. The proportions of all graduates in family practice and of graduates serving rural Washington as family physicians had increased over that of a cohort of students who had entered the University of Washington prior to the introduction of the pathway curriculum. These proportions surpassed the goals set at the time the new curriculum was introduced. CONCLUSION With early identification and support of students interested in family practice, an increased number entered the specialty and were still family physicians in mid-career.

Little is known about what students perceive they are taught about suffering in medical school. We sought to explore medical student perceptions of their medical school education about suffering.We used an online survey of medical students enrolled in four US medical schools with chi-square analysis of responses by gender and preclinical/clinical status.A total of 1,043 students (38%) responded and indicated that teaching about suffering is occurring in the schools surveyed. Respondents most strongly endorsed statements that their medical school education explicitly teaches that the relief of suffering is an inherent function of being a physician (46.5%) and that most of what they learned about dealing with suffering patients is taught by modeling (46.6%). They reported that their education explicitly teaches about suffering (32.8%), provides a good understanding of suffering (31.7%), and teaches how to interact with suffering patients (31.7%). Students gave the least support to statements that their education prepares them to personally deal with their reactions to the suffering of patients (25.1%) and teaches how to diagnose suffering (15.3%). Responses varied markedly according to gender and clinical status at two of the four schools surveyed.Teaching about suffering is occurring in the schools surveyed and can be variably experienced according to gender and clinical status. Implied curricular gaps include teaching about how to diagnose suffering and how to personally deal with the feelings that arise when caring for suffering patients. Further research on how students are learning about suffering is warranted to guide curriculum development and implementation.

Background: Communication failures in healthcare teams are associated with medical errors and negative health outcomes. These findings have increased emphasis on training future health professionals to work effectively within teams. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) communication training model, widely employed to train healthcare teams, has been less commonly used to train student interprofessional teams. The present study reports the effectiveness of a simulation-based interprofessional TeamSTEPPS training in impacting student attitudes, knowledge and skills around interprofessional communication.Methods: Three hundred and six fourth-year medical, third-year nursing, second-year pharmacy and second-year physician assistant students took part in a 4 h training that included a 1 h TeamSTEPPS didactic session and three 1 h team simulation and feedback sessions. Students worked in groups balanced by a professional programme in a self-selected focal area (adult acute, paediatric, obstetrics). Preassessments and postassessments were used for examining attitudes, beliefs and reported opportunities to observe or participate in team communication behaviours.Results: One hundred and forty-nine students (48.7%) completed the preassessments and postassessments. Significant differences were found for attitudes toward team communication (pConclusions: Effective team communication is important in patient safety. We demonstrate positive attitudinal and knowledge effects in a large-scale interprofessional TeamSTEPPS-based training involving four student professions.

To examine the relationship between resident physicians' perceptions of their preventive cardiology practices and a chart audit assessment of their documented services.A criterion standard comparison of two methods used to assess resident physicians' practices: self-report and chart audit.Physician ambulatory care in a residency program.Coronary artery disease (CAD) risk factor assessment was evaluated by self-report for 72 resident physicians and by chart audit of randomly selected records of 544 of their patients who did not have CAD or a debilitating chronic disease during a one-year period.Measurements of the residents' perceived CAD risk factor assessment practice by self-report, and chart audit assessments of their recorded care.The relationship between self-reported and chart audit assessments of CAD risk factors.Chart audit assessment of CAD risk factor management was highly significantly (p0.01) lower than self-reported behaviors for evaluation of cigarette smoking, diet, physical activity, stress, plasma cholesterol, blood pressure, and body weight/obesity.Three different interpretations of these findings are apparent. 1) Physician self-report is a poor tool for the measurement of clinical behavior, and therefore research of physician behavior should not rely solely on self-reported data; 2) physicians' chart recording of their clinical practice is insufficient to reflect actual care; or 3) neither is an accurate measure of actual practice.

Integrated clinical clerkships represent a relatively new and innovative approach to medical education that uses continuity as an organizing principle, thus increasing patient-centeredness and learner-centeredness. Medical schools are offering longitudinal integrated clinical clerkships in increasing numbers. This report collates the experiences of medical schools that use longitudinal integrated clerkships for medical student education in order to establish a clearer characterization of these experiences and summarize outcome data, when possible.The authors sent an e-mail survey with open text responses to 17 medical schools with known longitudinal integrated clerkships.Sixteen schools in four countries on three continents responded to the survey. Fifteen institutions have active longitudinal integrated clerkships in place. Two programs began before 1995, but the others are newer. More than 2,700 students completed longitudinal integrated clerkships in these schools. The median clerkship length is 40 weeks, and in 15 of the schools, the core clinical content was in medicine, surgery, pediatrics, and obstetrics-gynecology. Eleven schools reported supportive student responses to the programs. No differences were noted in nationally normed exam scores between program participants and those in the traditional clerkships. Limited outcomes data suggest that students who participate in these programs are more likely to enter primary care careers.This study documents the increasing use of longitudinal integrated clerkships and provides initial insights for institutions that may wish to develop similar clinical programs. Further study will be needed to assess the long-term impact of these programs on medical education and workforce initiatives.

The relationship between oral contraceptive use and other coronary artery disease risk factors was examined in 215 nonsmoking women grouped as never, current, or previous users. Current oral contraceptive users had higher triglyceride levels (p less than or equal to 0.001) than other groups, higher systolic blood pressure, and lower plasma HDL-cholesterol levels (p less than or equal to 0.05) than previous users. The effect of oral contraceptive use on plasma triglyceride values persists on multivariate regression analysis independently of age, body mass index, dietary sodium and cholesterol intake, cigarette smoking, and level of physical activity. Oral contraceptive use also has an independent relationship to the plasma total cholesterol/HDL- cholesterol ratio. These findings indicate that oral contraceptive use is adversely associated with plasma lipid and lipoprotein values.

Although concern about the clinical skills of medical school graduates is increasing, there is little consensus among faculty about what the essential clinical skills are for the general professional education of the physician. To identify such a common core of psychomotor skills, a survey questionnaire was mailed to faculty at the University of Washington School of Medicine. Forty‐three skills were determined to be essential for mastery by more than 60% of respondents. These results were then validated by a committee of clerkship directors who refined the list to 28 skills that should be required for graduation. These data are being used to specify educational objectives and to design clinical performance examinations.

Previous studies have associated commercial funding with positive outcomes in orthopaedic research. Those reports, however, failed to account for potential confounding variables that can lead to a disproportion of positive outcomes, including sample size, study design, and study quality. We tested the hypothesis that nonscientific factors (funding source, orthopaedic subspecialty, and geographic region of origin) are associated with positive study outcomes, but not the result of differences in study design, study quality, or sample size. All 747 abstracts presented at the 2004 American Academy of Orthopaedic Surgeons annual meeting underwent blinded analysis using previously published criteria. Studies that received commercial funding were more likely to conclude with positive outcomes. Subspecialty and country of origin were not associated with positive outcomes. Commercially funded studies were not more likely than non-funded studies to be well-designed. When control groups were used, those in commercially funded studies were not larger than those used in nonfunded studies. Our data suggest commercial funding was associated with positive outcomes, but we found no evidence to suggest commercially funded studies were better designed or larger than non-funded studies.

The Institute of Medicine's vision for health professions education specifies working together across professions and schools to provide patient-centered care. Improvement in collaborative preparation of health professionals is seen as central to achieving substantial improvement in the quality of health care. In this article, the authors address one central question: How can medical schools work with other health-sciences schools to promote their educational, research, and service missions? The authors summarize the history of the University of Washington (UW) Health Sciences Center in promoting interprofessional collaboration in education, service and research; analyze the key strategic, structural, cultural and technical elements that have promoted success or served as barriers in the development of the UW Center for Health Sciences Interprofessional Education and Research; and suggest strategies that may be transferable to other institutions seeking to implement an interprofessional health sciences program. These include both top-down and bottom-up authority and function in key working groups, institutional policies such as interprofessional course numbers and shared indirect costs, and development of a culture of interprofessionalism among faculty and students across program boundaries.

Departmental advisors who also serve on residency selection committees at their institutions have a dual role as advisor and evaluator of residency applicants.This study explores this dual role and its effect on medical students' confidence in the advising relationship.A secure, anonymous questionnaire was made available online to 1,362 graduating medical students from ten U.S. medical schools who participated in the 2001 match.Of the 740 respondents (54.3% response rate), 349 (47.2%) met with a departmental advisor at their medical school. Most (212 or 60.7%) had departmental advisors who also served on a residency selection committee. These applicants reported feeling significantly less comfortable with their advisors and were significantly more likely to make misleading statements during the match.Applicants whose departmental advisors serve on a residency selection committee have less confidence in the advising relationship. These interactions may have adverse effects on the clinical and professional development of medical students.

Faculty in the Department of Medical Education and Biomedical Informatics at the University of Washington School of Medicine received over $1.2 million in direct grant and contract support in 2003. In this case study, the authors provide some of the history and background of the evolution of the department's structure and its role in providing leadership in medical education research at the university, as well as regionally, nationally, and internationally. The authors offer their observations and reflections on what has helped and hindered the department's success, and end with some predictions on medical education research in the future. The University of Washington's five-state regional WWAMI educational program, establishing a single medical school for the states of Washington, Wyoming, Alaska, Montana, and Idaho, has been an important environmental influence on the direction of the department's educational and research activities. External support has helped the department to create the Northwest Consortium for Clinical Performance Assessment, the Center for Medical Education Research, the Teaching Scholars Program, and a Biomedical and Health Informatics graduate and fellowship training program, as well as a number of international programs.

Providing oral health care to rural populations in the United States is a major challenge. Lack of community water fluoridation, dental workforce shortages, and geographical barriers all aggravate oral health and access problems in the largely rural Northwest. Children from low-income and minority families and children with special needs are at particular risk. Family-centered disease prevention strategies are needed to reduce oral health disparities in children. Oral health promotion can take place in a primary care practitioner's office, but medical providers often lack relevant training. In this project, dental, medical, and educational faculty at a large academic health center partnered to provide evidence-based, culturally competent pediatric oral health training to family medicine residents in five community-based training programs. The curriculum targets children birth to five years and covers dental development, the caries process, dental emergencies, and oral health in children with special needs. Outcome measures include changes in knowledge, attitudes, and self-efficacy; preliminary results are presented. The program also partnered with local dentists to ensure a referral network for children with identified disease at the family medicine training sites. Pediatric dentistry residents assisted in didactic and hands-on training of family medicine residents. Future topics for oral health training of family physicians are suggested.

Objective: In 1975, Donald Light, Jr., presented a “sociological calendar” as a paradigm for describing the important dimensions and stages of social and professional development in psychiatric residency training. The authors sought to develop an updated calendar and to determine if the calendar is consistent with attitudes of residents in various stages of their training. Methods: A new sociological calendar was developed after conducting a focus group with chief residents. The Osgood Semantic Differential Survey (OSD) was used to measure residents’ attitudes, and the results were compared with the modified calendar. Results: The updated calendar differs considerably from Light’s original calendar. Findings from the OSD were generally consistent with the updated calendar. Conclusions: A modern sociological calendar illustrates the relatively predictable transitions that residents go through over the course of their training. By better understanding these stages of development, supervisors and residency directors may become more effective in their teaching and support efforts.

PURPOSE Communication between programs and applicants during the Match has raised concern among medical educators. This study explores the patterns of such communication and its effect on the ethical and professional development of medical students. METHOD In March and April 2001, the authors made a secure, anonymous questionnaire available online to 1,362 medical students who were graduating from ten U.S. medical schools and who participated in the 2001 Match. Data analysis included chi square, ANOVA, and correlation tests as appropriate. RESULTS A total of 740 students (54.3%) completed the questionnaire. Patterns of communication between programs and applicants varied significantly by medical school and specialty. Communication initiated by applicants came predominantly from those from less highly ranked medical schools (p =.000), and those applying to specialties with lower fill rates (p =.000). Programs initiated significantly more communication with applicants from more highly ranked schools (p =.006), and with those applying to specialties with higher fill rates (p =.000). The amount of pressure felt by applicants was related to the level of communication, whether initiated by applicants (p =.028) or programs (p =.000). Applicants who felt more pressure were significantly more likely to make misleading statements to programs (p =.000). CONCLUSIONS Communication between applicants and programs during the Match varies and may have adverse effects on the ethical and professional development of medical students. This study provides support for proposals to limit communication between programs and applicants during the residency selection process.

Purpose. To examine students' learning before and after revising an educational software program and to explore students' patterns of use of an interactive feature that compares images. Method. Study participants were 466 University of Washington School of Medicine students. Two cohorts of students (one in 1996 and one in 1997) used the original version of the software. Following analysis of the students' learning, the software program was modified based on instructional design principles pertaining to visual learning and concept acquisition. A 1998 cohort of students used the revised program and their performance was compared with that of the 1996 cohort. Analyses were based on pre- and post-test scores, data collected from the observation of students, and navigational pathways tracked by the program. Results. There was very little difference in the overall performances of the students who used the original program and those who used the revised program. Error analysis focusing on 11 conceptual areas showed that reductions in errors occurred for six of 11 concepts, with statistically significant reductions of errors for two concepts. Additional navigational data collected in 1998 showed that students used an interactive feature for comparing images in different patterns. The data showed a positive association between performance and the anchored viewing mode of image display. Conclusions. While this study cannot point to specific design components that facilitated or hindered learning, it demonstrated a potential benefit of linking usage-pattern data and performance. Future studies should evaluate design factors that affect usage patterns and performances based on navigational data collected while students interact with software programs.

This study identified characteristics of clinical teachers in ambulatory care settings that influenced ratings of overall teaching effectiveness and examined the impacts of selected variables of the clinic environment on teaching effectiveness ratings. A survey instrument derived from prior research and observations of ambulatory care teaching was sent to 165 senior medical students and 60 medicine residents at the University of Washington School of Medicine in 1988. A total of 122 (74%) of the seniors and 60 (71%) of the residents responded. Results indicate that the most important characteristics of the ambulatory care teachers were that they actively involved the learners, promoted learner autonomy, and demonstrated patient care skills. Environmental variables did not have a substantial influence on these ratings.

The Washington Primary Care Interest Inventory (WPCII) assesses student attitudes regarding the appropriateness of a range of biopsychosocial concerns for which a patient might seek care from a primary care provider. The WPCII holds promise for understanding the relationship between attitudes, career choice, gender, and cohort. Methods: We longitudinally examined WPCII scores across medical school cohorts and by gender. We also explored the influence of attitudes in predicting career choice. Results: Four findings emerged. First, WPCII scores were positively associated with student preferences for primary care specialties. Second, across 14 years, there has been a significant upward trend in WPCII scores. Third, women exhibit higher scores on the WPCII. Finally, WPCII scores at the start of medical school show some ability to predict student residency match. Discussion: We discuss the WPCII’s promise for understanding shifts in career choice and the influence of gender in selecting primary care specialties.

The results of a predictive validity study of the new Medical College Admission Test (MCAT) using criteria from the clinical years of undergraduate medical education are presented and discussed. The criteria included course grades and faculty ratings of clerks in internal medicine, surgery, obstetrics and gynecology, pediatrics, and psychiatry; scores on a comprehensive test of clinical knowledge (including patient management type examinations); and scores on Part II of the examinations of the National Board of Medical Examiners (NBME). While the validity coefficients of the MCAT with the Part II examinations ranged from .03 to .47, they were higher than those of undergraduate grade-point averages with the same criteria. The implications of the small-to-medium size validity coefficients for admissions are discussed.

Summary. The University of Washington School of Medicine (UWSM) has initiated new efforts to build a regional minority applicant pool and to expand its educational programmes to accommodate students from disadvantaged backgrounds. Specific interventions include: establishment of medical career planner position to coordinate region-wide outreach; pre-entry education; and support activities once enrolled. This study describes specific services and presents sociodemographic and performance data on 56 minority and 280 majority students entering the UWSM between 1981 and 1985. Economic status and educational background of minority students were significantly below that of majority students. While academic performance of minority students tended to fall below that of majority students, several flexible academic policies enabled most students to achieve mastery in courses and to progress through the curriculum. The educational data base utilized in this study, and those at other institutions, can assume important roles in the identification of problem areas in the education of disadvantaged students and in evaluation of the interventions attempted.

In the past decade, communication satellites have assumed an increasingly significant role in meeting world communication needs. Advocates project vast arrays of potential utilization for this distance independent technology. Such expansion of use depends upon user acceptance, a variable which has as a requisite dimension, the perception of trouble-free operation and similarity with face to face verbal interaction. Following two hundred twenty-two satellite-mediated broadcasts, the authors review the variety of user-related pitfalls which occurred during this experiment in health education and health care delivery. Specific consideration is given to those problems which need to be remedied for a “user acceptable” system of satellite communication in the health care arena. Though the technical system works, it is suggested that additional emphases upon participant acceptance are necessary before the technology will be widely accepted and utilized.

Since 1971, the University of Washington School of Medicine, Seattle, has operated a four-state, medical education program covering Washington, Alaska, Montana, and Idaho. This WAMI Program involves four universities without medical schools and 15 communities. To maintain this program, communication between the sites is imperative and mandates travel. The experiments described in this article were undertaken to determine whether full-duplex audio and color-video interactions via communications satellites could replace the travel requirements of the WAMI Program. Experiments involving the administration of the program, the presentation of the undergraduate medical education curriculum, the provision of health services, and the formation of public policies were conducted. The results suggest that satellite communication has broad applicability in medical education and health care provision. ( JAMA 1983;250:636-639)