Academic medicine : journal of the Association of American Medical Colleges
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It is widely recognized that interdisciplinary team care is essential for effective management of complex patients such as the frail elderly. Physicians need to understand the operational mechanisms that drive the team care model. While such concepts should be an integral part of medical education, teaching such a model of care that demonstrates effective provider communication, coordination of multiple services, and the provision of cost-effective health care can be difficult. The Program of All-inclusive Care of the Elderly (PACE) is a well-established, high-quality program that has been replicated nationally and can serve as an effective teaching model. Achieving the goals of the PACE program requires strong team leadership and communication, clear patient-oriented goal definition, an understanding and appreciation of roles among various disciplines, skillful negotiation, and shared responsibility for the patient. The PACE model offers medical and family practice residents a non-traditional clinical setting with educational opportunities not available in most hospital or ambulatory settings. ⋯ For most of the medical and family practice residents, this experience represents their first exposures to this model of coordinated team care for the elderly. Preliminary evaluation results indicate that residents have generally been unaware of the services available to the elderly and of the opportunities for coordinated care using the expertise of multiple disciplines. There is a lack of knowledge of key non-physician professional roles. The expanded use of PACE models as training sites could be beneficial in preparing future health care professionals for interdisciplinary team care of the growing numbers of frail elderly.
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Addressing the current fragmentation and lack of coordination of health care requires that health professionals be skilled and motivated towards interdisciplinary team care. The objectives of our program are to (1) enhance attitudes towards team health care and (2) improve group interaction skills among interdisciplinary health care learners. ⋯ Previous team-care training programs for health professionals have demonstrated difficulty in fostering effective attitudes and skills. During the planning and pilot year, we identified barriers to success that included (1) negative baseline attitudes toward interdisciplinary team care, especially among medical residents, (2) unrecognized assumptions and behaviors by learners regarding authority and power relationships within the team, and (3) specific concerns by learners regarding the effectiveness and efficiency of health care teams. We hope to demonstrate success through a program that includes direct examination of learners' attitudes and their origins in a safe environment, immediate feedback regarding group behaviors, case-based learning, and direct role exposure to a well-functioning interdisciplinary team.
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If faculty development programs are to have impact, we believe they should be made up of several self-reinforcing workshops that provide opportunities for behavior review, practice, reflection, and reinforcement within a context of interdisciplinary perspectives. A program was developed that supports these four activities and includes clinical faculty from medicine, dentistry, nursing, and pharmacy. ⋯ Several theories support these clinical teaching workshops. (1) Outcomes research in continuing medical education suggests the need for ongoing reinforcement, which we do structurally through the three-session model. (2) We use a classical microteaching approach to develop insight and self-awareness. Each videotaped encounter is reviewed, stopped at key points, and discussed by the entire group. These discussions commonly open up after the workshop leaders ask questions such as, "What were you thinking there?" or "What were you trying to do?" or "What would you ask next?" (3) We emphasize the importance of knowing-in-action and the related reflection that guides action in practice. (4) The quality of the workshops is enhanced using standardized students, whom we carefully train and use repeatedly. At least two students have worked with us from their first years through their final clinical years. We are currently examining the program's impact through videotape review.
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The teaching OSCE (objective structured clinical examination) was developed from existing OSCE materials to provide direct observation and feedback to students on their doctor-patient relationship skills, students' abilities to do a focused history and physical examination, and to familiarize students with this type of examination. ⋯ Our department has used OSCEs for six years to evaluate students at the end of the third-year family medicine clerkship. Even after continuous improvement, our OSCE did not meet higher standards of reliability and would need at least three hours of testing per student to meet those standards. The low number of students in the rotation and limited resources to increase the duration of the OSCE made it very difficult to construct a more reliable examination. At the same time, both faculty and students wanted more direct observation and feedback on performance with clinical scenarios. Using existing OSCE resources to change the OSCE to a teaching tool proved to be an efficient use of teaching resources while increasing our educational impact. Students report that they appreciate the opportunity to have constructive discussions of their strengths and weaknesses in clinical encounters, observe a variety of doctor-patient interaction styles, and practice for future OSCE-type examinations. Faculty members enjoy this active teaching format and find the process of students giving feedback to their peers educationally useful. The teaching OSCE has been extremely well rated in the end-of-rotation evaluations and will be continued in future clerkships.
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MEDICOL (Medicine and Dentistry Integrated Curriculum Online) provides a variety of Web-based resources that act as important adjuncts to all the teaching components of the medical and dental undergraduate curriculum. It uses WebCT, a course-management system, to provide the following educational functions: (1) track students' progress and present course information such as time-tables, learning objectives, handout materials, images, references, course assignments, and evaluations; (2) promote student-to-student and student-to-instructor interactions (through e-mail and bulletin boards); and (3) deliver self-directed learning components, including weekly self-assessment quizzes that provide immediate feedback and multimedia learning modules (clinical skills, radiology, evidence-based medicine, etc.). ⋯ Use statistics indicate that over 90% of students regularly use the MEDICOL sites and have found them helpful. University of British Columbia medical school enrollment will increase because of collaborations with campuses and medical centers across the province. MEDICOL will likely play an increased role in distance learning by continuing to deliver the resources already described, as well as facilitating synchronous communications (e.g., PBL chat rooms) and teaching (e.g., video-streamed lectures) to students located across the province.