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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: 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. [ABSTRACT FROM AUTHOR]

Background: 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.Methods: 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.Results: 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 (p < 0.01), which was not correlated with better performance. After instruction, performance improved significantly in all three training groups (p < 0.001), 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).Conclusions: 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. [ABSTRACT FROM AUTHOR]

Public Health Informatics (PHI) education began at the University of Washington (UW) with a Summer Institute in 1995. The Biomedical and Health Informatics graduate program, which is housed in the School of Medicine, is an interdisciplinary, multi-school program. It demonstrates the UW's cooperative efforts in advancing informatics, encompassing the schools of public health, medicine, nursing, dentistry, pharmacy, information and graduate schools in computer science. This article provides an overview of the developmental milestones related to activities in PHI and describes the evaluation strategy and assessment plan for PHI training at the UW ( http://phig.washington.edu ). [ABSTRACT FROM AUTHOR]

BACKGROUND: 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. PURPOSE: 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. METHODS: Two surveys were administered: an Information Literacy Survey for curriculum/informatics deans and a Computing Skills Survey for entering medical students. RESULTS: 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. CONCLUSIONS: 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. [ABSTRACT FROM AUTHOR]

Rationale: 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., Objectives: 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., Methods: 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., Measurements and Main Results: 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, P < 0.001) and Internal Medicine Certification Examination scores (β = 0.49, P < 0.001) 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., Conclusions: 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: This pilot study assessed the feasibility of using first person (1P) video recording with Google Glass (GG) to assess procedural skills, as compared with traditional third person (3P) video. We hypothesized that raters reviewing 1P videos would visualize more procedural steps with greater inter-rater reliability than 3P rating vantages., Methods: Seven subjects performed simulated internal jugular catheter insertions. Procedures were recorded by both Google Glass and an observer's head-mounted camera. Videos were assessed by 3 expert raters using a task-specific checklist (CL) and both an additive- and summative-global rating scale (GRS). Mean scores were compared by t-tests. Inter-rater reliabilities were calculated using intraclass correlation coefficients., Results: The 1P vantage was associated with a significantly higher mean CL score than the 3P vantage (7.9 vs 6.9, P = .02). Mean GRS scores were not significantly different. Mean inter-rater reliabilities for the CL, additive-GRS, and summative-GRS were similar between vantages., Conclusions: 1P vantage recordings may improve visualization of tasks for behaviorally anchored instruments (eg, CLs), whereas maintaining similar global ratings and inter-rater reliability when compared with conventional 3P vantage recordings., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objectives: 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., Methods: 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., Results: 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., Conclusions: 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: 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., Questions/purposes: We asked whether a minimally invasive approach to TKA is associated with lower inpatient charges and direct inpatient costs than the traditional approach., Patients and Methods: 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., Results: 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)., Conclusions: 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.

Background: The relief of suffering is a fundamental goal of medicine, but what medical students are taught about suffering has been largely unexplored., Objective: This pilot study explored the perceptions of physicians in postgraduate training of their medical school education about suffering., Design: Survey research involving physicians in postgraduate family medicine training programs., Results: One hundred eighty-four of 304 surveys were returned for a response rate of 61%. Respondents perceived significant gaps in their education about the understanding and diagnosis of suffering and in their preparation to deal with the feelings engendered by caring for suffering patients. Respondents generally perceived that they were prepared to interact with suffering patients and were taught that the relief of suffering is an inherent function of being a physician, but perceived that more explicit teaching about suffering would have better prepared them for residency training., Conclusions: Perceptions of the teaching about suffering at the medical school level are quite variable with significant curricular gaps in student instruction about suffering and its relief.

Background: Research on the outcomes of pre-clinical curricula for clinical skills development is needed to assess their influence on medical student performance in clerkships., Objective: To better understand the impact of a clinical-skills curriculum in the pre-clinical setting on student performance., Design: We conducted a non-randomized, retrospective, pre-post review of student performance evaluations from 3rd-year clerkships, before and after implementation of a clinical-skills curriculum, the Colleges (2001-2007)., Main Results: Comparisons of clerkship performance data revealed statistically significant differences favoring the post-Colleges group in the Internal Medicine clerkship for 9 of 12 clinical-skills domains, including Technical Communication Skills (p < 0.023, effect size 0.16), Procedural Skills (p < 0.031, effect size 0.17), Communication Skills (p < 0.003, effect size 0.21), Patient Relationships (p < 0.003, effect size 0.21), Professional Relationships (p < 0.021, effect size 0.17), Educational Attitudes (p < 0.001, effect size 0.24), Initiative and Interest (p < 0.032, effect size 0.15), Attendance and Participation (p < 0.007, effect size 0.19), and Dependability (p < 0.008, effect size 0.19). Statistically significant differences were identified favoring the post-Colleges group in technical communication skills for three of six basic clerkships (Internal Medicine, Surgery, and Pediatrics)., Conclusions: Implementation of a pre-clinical fundamental skills curriculum appears to be associated with improved clerkship performance in the 3rd year of medical school, particularly in the Internal Medicine clerkship. Similar curricula, focused on teaching clinical skills in small groups at the bedside with personalized mentoring from faculty members, may improve student performance. Continued efforts are needed to understand how to best prepare students for clinical clerkships and how to evaluate outcomes of similar pre-clinical skills programs.

Purpose: 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., Method: The authors sent an e-mail survey with open text responses to 17 medical schools with known longitudinal integrated clerkships., Results: 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., Conclusions: 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.

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.

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.

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 < 70%. Higher examination scores were associated with male gender (p = 0.01) and participation in a musculoskeletal course (p = 0.009). Practitioners who took elective courses demonstrated higher scores compared with those who took required courses (p = 0.014). Greater musculoskeletal confidence was associated with the number of years in clinical practice (p = 0.045), male gender (p = 0.01), residency training in family practice (p < 0.00001), and prior participation in a musculoskeletal course (p = 0.0004). Physicians demonstrated greater confidence with medical issues than with musculoskeletal issues (mean confidence scores, 8.3 and 5.1, respectively; p < 0.00001). Higher scores for musculoskeletal knowledge correlated significantly with increasing levels of musculoskeletal confidence (r = 0.416, p < 0.0001)., Conclusions: Although a large proportion of primary care visits are for musculoskeletal symptoms, the majority of primary care providers tested at a large, regional, academic primary care institution failed to demonstrate adequate musculoskeletal knowledge and confidence. Further characterization of the relationship between knowledge and confidence and its association with demographic variables might benefit the education of musculoskeletal providers in the future.

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 first 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 significantly more likely than degree holders to work in primary care and nonmetropolitan areas. Respondents with no degree at program entry were significantly 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 significantly more likely to demonstrate a commitment to primary, rural, and underserved health care. These findings may inform the national debate about the impact of required advanced degrees on the practice patterns of nonphysician providers.

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.

Background: Departmental advisors who also serve on residency selection committees at their institutions have a dual role as advisor and evaluator of residency applicants., Purpose: This study explores this dual role and its effect on medical students' confidence in the advising relationship., Methods: 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., Results: 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., Conclusions: 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.

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 non-governmental 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.

Background: The Institute for International Medical Education has published "Global Minimum Essential Requirements (GMERs) in Medical Education.", Purpose: This study examined attitudes of a sample of Chinese medical students toward the GMERs., Methods: Matriculating and graduating West China School of Medicine Sichuan University medical students were administered parallel surveys during the 2001 to 2002 academic years., Results: 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., Conclusion: 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 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.

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.

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.

Purpose: To describe the development of the Washington Primary Care Interest Inventory (WPCII), which was designed to assess attitudes toward what constitutes appropriate psychosocial concerns for visiting a family physician, and to demonstrate the relationship between these attitudes and specialty selection in matriculating medical students., Method: Five entering classes of medical students (1990 to 1995, without 1992) at the University of Washington were administered the WPCII during orientation. Reliability, factor, and predictive validity analyses were performed to measure the utility of the WPCII., Results: Factor analysis revealed three interpretable factors to underlie the WPCII: stressors, physical complaints, and familial complaints. Scales developed from these factors correlated with students' early career preferences and showed significant differences across students who were selected under different interviewing formats. Differences between the sexes were found for both specific items and scales., Conclusion: The WPCII is a reliable and valid measure of attitudes toward the appropriateness of family physicians' treating psychosocial complaints. These attitudes have implications for the selection of medical students, curriculum development, assessment, and health education research.

A study was undertaken to determine (1) the likelihood that patients seen for episodic health care in a family medical center have been assessed and counseled for coronary heart disease (CHD) risk factors, and (2) the likelihood that patients having an identified risk factor have been assessed and counseled regarding other CHD risk factors. One thousand five hundred twenty-eight medical records were randomly selected from all visits occurring over two periods in 1986 and 1987 to 122 residents in an eight-site family medicine residency network. Patients with cardiovascular disease and those younger than 20 or older than 65 years of age were excluded. Assessments were made of (1) smoking history, blood pressure, weight, physical activity, and dietary content during the previous 12 months; (2) family history of cardiovascular disease during the previous 12 months and in the initial patient history; (3) and blood cholesterol during the prior 5 years. Risk-factor counseling practices were examined for the previous 12 months. Blood pressure was assessed in 96% of patients, smoking in 40%, cholesterol in 26%, and family history in 52%. Ninety-six percent of hypertensive patients were counseled for hypertension, but only 45% of smokers and 20% of patients with hypercholesterolemia were counseled for those risk factors. Of patients having a given risk factor, assessment for any other risk factor occurred in fewer than 60% of cases. Patients having a documented positive family history were only slightly more likely than other patients to be assessed for additional risk factors. There is continued need for enhancing coronary risk-factor assessment and counseling by resident physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for cardiovascular disease are commonly obtained in freshman medical students for the purpose of increasing interest and awareness in preventive cardiology. What would be a normal range of values for this select group? This paper describes the major cardiovascular risk factors for 3,811 male and female freshman medical students from eight U.S. medical schools that were obtained in a standardized fashion as part of the Preventive Cardiology Academic Award (PCAA) programs at these institutions. The distributions of height, weight, Quetelet index, systolic and diastolic blood pressures, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and calculated low-density lipoprotein cholesterol are presented for male and female medical students stratified by race into white, black, Asian, and Hispanic groups. The sex and race distributions of cardiovascular risk factors such as previously diagnosed hypertension, diabetes mellitus, smoking, lack of regular exercise (three times a week or more), oral contraceptive use in women, and family history of coronary heart disease are presented. The cardiovascular risk of freshman medical students is compared to other epidemiologic studies of young adults. The use and limitations of these race- and sex-specific data on cardiovascular risk, including physiologic measurements, are discussed in the context of educational programs for medical students and house staff in preventive cardiology.

This paper presents results from two studies of primary care residency programs. Study I was a survey of preventive cardiology attitudes and practice-related intentions of internal medicine and family medicine residents from throughout the United States. Study II consisted of an examination of family medicine residents' perceptions regarding preventive practices and a series of 1,528 medical record reviews of their related assessment and counseling practices. The specific aims were to examine residents' perceptions about their residency programs and to determine the percentages of patients who were assessed for and, if necessary, counseled for coronary heart disease prevention. Results indicated that internal and family medicine residents believe that they should be prepared by their residency training to offer these services and that their residencies were preparing most of them to do so. While they report that they intend to assess and counsel patients in these areas, they do not seem to be doing so. The medical record reviews strongly indicated that they are not providing these services at the recommended levels, especially for assessment of and counseling for smoking and blood cholesterol levels.

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.

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, 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.