Mid Coast Hospital

Introduction: Feedback is essential for performance improvement and plays a pivotal role in competency-based medical education. Medical learners need training to acquire skills to effectively seek feedback for their unique situations. Methods: We developed a 4-year longitudinal curriculum designed to encourage feedback-seeking by medical students. The 4.5-hour curriculum consisted of interactive lectures, feedback-seeking surveys, trigger videotapes, and peer-group discussions in small- and large-group formats. A volunteer study cohort (n = 14/37, 38%) was interviewed in 4 separate waves in individual and focus-group formats to explore perceptions about feedback-seeking and effectiveness of the curriculum. Results: Themes and student quotes related to the learning objectives were summarized. The students expressed appreciation for the value of seeking feedback. They appreciated the techniques they learned and the frequent reminders. They particularly appreciated the opportunities to share successes and failures related to feedback-seeking with their peers. Discussion: Our novel feedback-seeking curriculum supported students’ understanding of the importance of feedback and their effective use of multiple feedback-seeking techniques. The longitudinal component supports greater opportunity for building space in the curriculum, incorporating reflection and reinforcement, and creating capacity for student application and technique refinement. Conclusions: Teaching students feedback-seeking through various techniques tailored for their unique situations, rather than waiting to potentially receive feedback, is important for their professional development and overall medical education.

INTRODUCTION: Entrustable Professional Activities (EPAs) have been proposed for use in undergraduate medical education. The ability of faculty to entrust students with EPAs may differ between Longitudinal Integrated Clerkships (LICs) and traditional block clerkships. METHODS: Participants were core clerkship faculty, 64 in a LIC and 31 in a sequential block clerkship. We administered a web-based survey at the end of the core clerkship year to measure preceptors’ typical entrustment (on a scale of 0–10) in students for the 13 American Association of Medical Colleges Core EPAs. We compared entrustment between LIC and block faculty using a Mann-Whitney test. RESULTS:LIC faculty were more entrusting of students than block faculty in 12 out of 13 Core EPAs (p DISCUSSION: LIC faculty were more likely than block clerkship faculty to entrust core clerkship students with performance of most EPAs. This finding is likely the result of LIC faculty having increased familiarity with student abilities because of the continuity of supervision and education inherent to LIC. More research is needed to ascertain the specific features of longitudinal clerkships that increase faculty entrustment of students. CONCLUSIONS: Longitudinal educational experiences may facilitate the assessment of medical students with EPAs.

Many nurse researchers have designed strategies to assist health care practitioners to move evidence into practice. While many have been identified as "models," most do not have a conceptual framework. They are unidirectional, complex, and difficult for novice research users to understand. These models have focused on empirical knowledge and ignored the importance of practitioners' tacit knowledge. The Communities of Practice conceptual framework allows for the integration of tacit and explicit knowledge into practice. This article describes the development of a new translation model, the Multisystem Model of Knowledge Integration and Translation, supported by the Communities of Practice conceptual framework.

In an attempt to improve the gait of people with Parkinson disease (PD), researchers have examined the effect of visual cues placed on the floor. These studies typically have used a single session of training with such cues and have not examined the long-term carryover of such training. In the present study, therefore, gait was analyzed during uncued, cued, and retention phases, each lasting 1 month. A 78-year-old woman who had been diagnosed with PD 12 years previously (Hoehn and Yahr classification of disability, stage III) volunteered for the study. During the initial uncued gait phase, the subject was required to walk a distance of 10 m as many times as she could in 30 minutes, 3 times per week for 4 weeks. During the 4-week cued gait phase, visual cues were placed on the floor along the 10-m walkway. The cues were initially 110% of the uncued step length and were later increased to 120%. Following this cued gait phase, the subject's gait was recorded periodically for 1 month without cues available. Step length, gait speed, and 2-dimensional lower-limb kinematics were compared within and across the 3 experimental phases. Celeration lines were calculated for the initial uncued phase and then extrapolated across the cued training and uncued retention phases. Binomial tests were used to analyze the significance of changes from the initial phase of the experiment. Step length (0.53-0.56 m) and gait speed (0.77-0.82 m x s(-1)) were essentially unchanged during uncued gait training after the first day; however, during the cued gait phase, gait speed improved, from 0.87 m x s(-1) to 1.13 m x s(-1), as step length was increased with visual cues. Improvements in step length (0.68 m) and gait speed (1.08 m x s(-1)) were still evident 1 month following the removal of the cues. Analyses of angle-angle diagrams and phase-plane portraits revealed that training with visual cues increased hip and knee range of motion and engendered more stable motor control of the lower limb. In contrast to previous studies in which the benefits of visual cueing were relatively short-lived, in this study, 1 month of gait training with visual cues was successful in establishing a lasting improvement in gait speed and step length while increasing the stability of the underlying motor control system.

Managed care physicians express many concerns about difficulties they experience in communicating and relating to patients (Table 1). These concerns are not limited to managed care, but the conditions and arrangements of managed care practices create unique issues. For in daily patient care, physicians encounter an astonishing variety of personalities in their patients, who have perplexing, unpredictable, and fatal illnesses. Serious illness and uncertainty provoke emotional distress in patients and their doctors.1 The explosion of medical knowledge introduces enormous complexity into medical work and the demands of keeping current are severe. Among the problems doctors face are setting limits, giving complex explanations, working with difficult emotions, managing disagreements, detecting and managing mental illness, discussing end–of–life matters, resolving cultural and racial issues, and talking with patients' relatives.2 Unfortunately, physicians seldom approach these and other interviewing problems in a focused or systematic manner, and frequently lack expert communication skills, whether they are generalists or specialists, in managed care settings or not.3 Table 1 Communication and Interview Dilemmas of Managed Care Physicians* Some of these predicaments are magnified by managed care.4, 5 Patients may be dissatisfied when they lack a choice of plan or physician.6 Often they feel entitled to more than the allowed benefits or misunderstand those limits, and the physician has to bear the bad news when something requested is denied or not covered. Patients are scheduled for increasingly shorter visits without respect to individual physician style or visit complexity. The plan creates ambiguity in the relationship: for whom is the doctor working, and is the plan or the doctor responsible for quality, care, and decision making?7 As participants in a seemingly impersonal system, patients worry their confidentiality will be breached. Plans that exclude mental health services may limit the physician's role in situations that patients would like their doctor to handle.5, 8 Plan success in the marketplace is critically determined by the relationships between practitioners and their patients. As plans' ability to cut costs vanishes (many plans have cut costs more than they can afford), the major way they can sustain enrollment is to improve the quality of communications and relationships.9 As Cleary and Edgman-Levitan put it, “being treated with respect and being involved in treatment decisions, aspects of care not included in many satisfaction surveys, are paramount issues for patients.”10 Complaints, suits, and quality of word–of–mouth recommendations all affect plan enrollment. One aspect of care most determined by the interview concerns mental disorders and psychosocial issues, as data about these derive from the interview and only come out in a trusting relationship. Mental disorders and psychosocial issues contribute heavily to plans' unnecessary costs.11 For example, patients referred to mental health departments average 11 medical visits in the year prior to the referral, and only 4 the subsequent year.12 A hospitalized patient comorbid for untreated depression costs an additional $2,500. To assist physicians and managed care plans that seek to improve relationships and communications skills in their practitioners, this article reviews data on the importance of interviewing, outlines the published evidence about teaching strategies, details one such course for managed care as an example of how these issues are approached, and concludes with steps recommended for organizations wishing to establish local programs on doctor–patient relationships and the medical interview.