Academic medicine : journal of the Association of American Medical Colleges
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The purpose of the migrant health initiative is to give medical students the opportunity to provide clinical services, at appropriate levels of training, to a population that reflects a different ethnic and economic background than medical students typically see in the clinical setting. This initiative integrates concepts of cultural competency with experiential learning. ⋯ The partnership between students, faculty, and the community provides the mechanism to thoughtfully develop and integrate cultural issues and experiences into the curriculum. Students have recently received a Caring for Community five-year grant from the Association of American Medical Colleges. Program expansions will continue into the third-year medicine clerkship and include a senior elective. The program expansions will result in a migrant health initiative that will be coordinated; comprehensive; and expand student knowledge, skills, and experiences in cultural health care.
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Teaching and learning in the ambulatory setting have been described as inefficient, variable, and unpredictable. A model of ambulatory teaching that was piloted in three settings (1973-1981 in a university-affiliated outpatient clinic in Portland, Oregon, 1996-2000 in a community outpatient clinic, and 2000-2001 in an outpatient clinic serving Dartmouth Medical School's teaching hospital) that combines a system of education and a system of patient care is presented. Fully integrating learners into the office practice using creative scheduling, pre-rotation learning, and learner competence certification enabled the learners to provide care in roles traditionally fulfilled by physicians and nurses. ⋯ The time spent alone with patients, in direct observation by preceptors, and for scheduled case discussion was appreciated by learners. Increased satisfaction was enjoyed by learners, teachers, clinic staff, and patients. Barriers to implementation include too few examining rooms, inability to manipulate patient appointment schedules, and learners' not being present in a teaching clinic all the time.
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Internal medicine residency training programs typically emphasize biomedical learning, but relatively few provide opportunities for residents to improve outpatient interviewing skills or to address challenging patient encounters. Even fewer programs provide resources to assess patient-resident relationship skills. To address these issues, we developed a curriculum that is designed to enhance patient-centered interviewing techniques in residents. ⋯ When the seminars were originally developed, we anticipated that this innovative combination of traditional individual videotape review with small-group learning would encourage self-directed learning. Indeed, over the last three years, residents have become more confident with their interviewing capabilities and less self-conscious about showing their own videotaped interviews. As a result, the seminars have unexpectedly evolved into a highly sophisticated series of learning modules, in which residents seek their most challenging patient encounters to videotape and show to the group. Residents have presented complicated scenarios involving critical patient-physician conflicts, somatizing patients, cross-cultural communication difficulties, overzealous family members, patients with substance abuse, and bad-news interviews. These dilemmas represent fundamental management challenges that are difficult to discuss in a more didactic format, and the immediate case-based nature of the interviews makes these often-emotional issues come alive. The group videotape reviews also give residents opportunities to reflect on their own interviewing encounters, to observe other interviewing styles and techniques, and to provide support to their fellow residents after particularly emotional interviews. An ancillary benefit of these exercises is that we have now developed a library of challenging interviews, which are easily accessible for further teaching seminars. Our residents consider this learning experience to be one of the most positive of their residency and valuable for their professional development. Residents report that this small-group seminar series has markedly improved their communication with patients, and they now clamor for the opportunity to present interviewing dilemmas. We believe that similar curricula can be readily instituted at other residency programs.
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While didactic conferences are an important component of residency training, delivering them efficiently is a challenge for many programs, especially when residents are located in multiple sites, as they are at Wayne State University School of Medicine in the Department of Family Medicine. Our residents find it difficult to travel from our hospitals or rotation sites to a centralized location for conferences. In order to overcome this barrier, we implemented distance learning and electronically delivered the conferences to the residents. ⋯ E-conferencing proved to be an effective method of delivering didactics in our residency program. Its many advantages included ease of use, cost-efficiency, and wide availability of equipment. Residents had the advantage of both geographic and temporal independence. Our e-conferences were interactive, and in addition to a PowerPoint presentation, faculty provided Web sites and hyperlinks for references. Initial problems included slow-speed connection, the requirement for digital materials, and the need for residents and faculty to adjust to a new learning method. There was also a need for increased coordination at the sites and reliance on electronic communication. To assess the effectiveness of the program, residents completed knowledge pre- and post-tests and a conference evaluation form. We also monitored conference attendance rates. Preliminary results indicated positive resident attitudes toward distance learning and significant increases in conference attendance. To objectively evaluate this instructional delivery method, we will compare residents' knowledge gains in the face-to-face instructor group with those of the group to which the lecture is broadcast. Ultimately, we are hoping to offer this educational opportunity to other family practice residency programs in the area, to medical students interested in family medicine, and to community family physicians for continuing medical education. We are considering the addition of streaming video to the presentations in the future, once the bandwidth of the Internet connections is sufficient.
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To promote greater sensitivity to and heightened awareness of the relevance and therapeutic potential of integrating medicine and spirituality in the healing process of patients cared for by our medical residents. Strategies for clear, effective, and empathetic communication are integrated into the curriculum. ⋯ Traditionally, graduate medical education has not emphasized the importance of spirituality as a "target" for routine inquiry, understanding, and sharing in the context of patient care. We are beginning to see that residents need to be aware of the relationship between spirituality and health, as a consequence of this curriculum. Because the curriculum is seamlessly integrated into a preexisting infrastructure (e.g., noon conferences, ambulatory off-site experiences, walk-rounds, etc.), it has been relatively easy to implement. Focusing on the literature has also provided a "scientific door" that has made this more palatable. Over time, we will foster a growing alliance of the medical and faith communities in our rural area. This has potent implications for community health initiatives. Two of our residents have already volunteered to give talks at local congregations. Spirituality and religion are sensitive and personal areas that can be awkward to embrace and openly discuss. By remaining sensitive and respectful of all views, we strive to diminish the obstacles and enable a more provocative, enlightening residency experience. As a consequence, we are forced to reconsider what it is to be a "healer" and what it is to be "healed." Annual verbal and written feedback will allow us to refine our curriculum. I anticipate this to be a permanent aspect of our residents' training.