Fidler H, Lockyer JM, Towes J, et al: Changing physicians' practices: the effect of individual feedback. Acad Med 1999; 74:702—714
Physicians in this study had participated in an earlier study in which they received feedback about their medical practices that had been obtained from patients, physician peers, non-M.D. co-workers, and referring/referral physicians. Three months later, they were sent a survey to determine what changes, if any, they had made or had thought about making as a result. They were also asked about what resources would be helpful to them in making these changes.
Of the 308 participants in the original study, 255 (83%) responded to the questionnaire. The questionnaire asked about 31 aspects of practice classified into five major areas: collegial communication and relationships; clinical skills and resource use; professional development and personal stress management; communication and support of patient; and office staff and office systems. Respondents indicated whether feedback had caused them to contemplate a change, initiate a change, decide no change was necessary because the feedback supported their present procedures, or not consider a change because the item was not applicable to them.
Across all the items, over 66% of the physicians reported that they had initiated at least one change after receiving feedback, and 83% were contemplating at least one change. The physicians who reported that they were either contemplating or had initiated changes had received significantly lower ratings in the initial study than had those who now indicated no change was necessary.
The items with the highest percentages of reported changes were in the area of patient communication and support. About 15% of the physicians had initiated changes related to giving patients better explanations about medication side effects and about how to avoid an illness or problem and making printed material available to patients. In the area of collegial communication and relationships, the highest percentages initiating change (12%) did so in their written and verbal communications with other professionals, including writing prescriptions more clearly.
In the area of clinical skills and resource use, the highest percentage initiating change (about 10%) altered their approach to complex medical problems by consulting more with peers and referring physicians. With regard to office staff and support systems, about 11% had worked to enhance communication among staff, improve telephone and answering systems, and reduce waiting time. About 13% had become more involved in professional development, and 23% had initiated changes in the management of personal stress.
The physicians also indicated their preferences for CME materials to make the contemplated or initiated changes. The options included printed materials, CME programs, audiotapes, videotapes, and the Internet. For all categories of practice, the highest percentage of physicians identified printed material as the CME format they preferred to help them meet their educational needs.
The authors concluded that, "Our study is helpful in that its findings suggest that individual feedback is effective in facilitating changes, particularly changes that are easy to make and controllable by the physician within a short (in this case, a 3-month) period. The study also highlights the continued importance to physicians of printed materials, a CME format they are familiar with and can control" (p 712).
Robins LS, White CB, Fantone JC: The difficulty of sustaining curricular reforms: a study of "drift" at one school. Acad Med 2000; 75:801—805
Major changes were made in the first-year curriculum at the University of Michigan Medical School in the early 1990s. These included more emphasis on teaching the basic sciences in a clinical context and greater utilization of more active learning methods along with adoption of a more centralized governance structure and faculty evaluation system. To identify factors that had facilitated or hindered achievement of the new curricular goals, faculty were sent a questionnaire in 1993 and 1997, and in 1998 faculty focus groups were held.
The survey responses indicated that between 1993 and 1997, the amount of time in the curriculum devoted to the humanities, social sciences, and ethics decreased despite the goal of providing a firm foundation in these areas. The basic scientists felt that this material was being taught prematurely and at the expense of essential basic science content. The percentage of the curriculum taught by lecture increased from 49% to 60%, which was more than the faculty thought was ideal. In the focus groups, faculty indicated that because of the pressure to generate revenue through research and/or patient care, they did not have enough time and energy to focus on educational activities. They also described institutional support for teaching as inadequate.
In order to reinvigorate the curriculum innovation efforts, the authors suggested changing the way in which institutional funds for teaching activities were allocated to departments and faculty members and increasing the amount of financial support. Ways to renew faculty consensus about educational goals and objectives also need to be identified.
Edelstein RA, Reid HM, Usatine R, et al: A comparative study of measures to evaluate medical students' performances. Acad Med 2000; 75:825—833
The fourth-year medical students at the three programs affiliated with the University of California, Los Angeles, School of Medicine were assessed with two new examinations, one that was computer-based (CBX) and one that utilized standardized patients (SPX). Both formats were under development by the National Board of Medical Examiners for possible inclusion in the licensure process. The CBX consisted of 10 case simulations that were designed to measure clinical decision-making. The SPX consisted of eight encounters with SPs that assessed a broad range of clinical skills.
In addition to these measures, demographic data, pre-medical school data, medical school GPAs, specialty choice, and scores for USMLE Steps 1 and 2 were available. The students also completed a survey that asked how well they felt various measures assessed their competencies.
The correlation between the CBX and the SPX was 0.24 (0.40 corrected for attenuation). The correlations between the CBX and Steps 1 and 2 were 0.32 and 0.40, respectively, and they were 0.25 and 0.30 between the SPX and Steps 1 and 2. The correlations with medical school GPAs were of similar magnitude. The pre- medical school measures were relatively low-level predictors of performance on the two new tests.
The students rated the CBX the best tool for assessing clinical decision-making skills. The best tool for assessing overall ability as a doctor was thought to be residents' reports, and attending physicians' reports were rated as the best tool to assess a doctor as a potential caregiver for a family member.
The authors concluded that the new testing methods assessed different dimensions of physician competency than did the traditional measures and recommended long-term studies to determine whether these measures predicted practice performance.
Patel VL, Cytryn KN, Shortliffe EH, et al: The collaborative health care team: the role of individual and group expertise. Teaching and Learning in Medicine 2000; 12:117—132
Discussions of professional competence usually emphasize individual knowledge, skills, and abilities, yet professionals often work in a relatively complex team environment that requires additional skills for effective collaboration. This observational study, which took place in a primary-care unit, was designed to characterize team decision-making processes; it focused on the structure of the team and on communication patterns among team members in relation to individual knowledge and expertise.
The primary-care unit, an ambulatory clinic in a large tertiary teaching hospital, was staffed by three primary-care physicians, a psychiatrist, two medical residents, two nurse-practitioners, one clinical nurse, one social worker, one HIV case manager, one community resources specialist, and two administrators. Each team member was observed for one-half to one day. Semi-structured interviews were also conducted, and data about telephone and e-mail interactions were collected.
It was found that roles within the health care team were clearly delineated. Continuous care was provided by the primary health care team, with intermittent specialized care delivered by consultants. Interactions among team members were driven by the needs of patients. Face-to-face and telephone conversations were more often used for patient care issues, whereas voice-mail and e-mail were used for administrative issues.
Patel et al. noted that, "the basis of collaborative functioning by the team remains predominantly dependent on the expertise of the individual, which is then combined with that of other individuals to provide a whole that is greater than the sum of its parts" (p 130). They added that this study does not address the issue of whether efficient team functioning results in more effective patient care.