Direct trainee observation: opportunities for enhanced physician-patient communication and faculty development

Medical students' knowledge and perception of irritable bowel syndrome in comparison to inflammatory bowel disease

BACKGROUND

Gastroenterologists may hold less positive attitudes toward disorders of gut-brain interaction (DGBI) like irritable bowel syndrome (IBS) compared with organic GI disorders like inflammatory bowel disease (IBD). This contributes to worse health outcomes in patients with DGBI and decreased patient satisfaction. Medical student knowledge and perception of these two disorders have not been directly studied.

METHODS

A cohort of medical students (n = 106) completed a survey where they read clinical vignettes about patients with IBS and IBD and answered questions regarding their knowledge of and attitudes toward these two diseases.

KEY RESULTS

IBS was perceived as a less real and a more exaggerated disorder when compared to IBD, and patients with IBS were seen as more difficult to treat. With more clinical exposure across 4 years of training, students were more likely to perceive IBS as a "less real" illness, though they held fewer negative attitudes toward patients with IBS. Greater familiarity with both IBS and IBD was associated with fewer negative attitudes.

CONCLUSIONS & INFERENCES

Biases observed in gastroenterologists toward patients with IBS originate as early as the beginning of medical school, including seeing IBS as a "less real" disease and more difficult to treat. Earlier educational interventions may be helpful in identifying and addressing these biases.

Assessment of Abilities of Gastroenterology Fellows to Provide Information to Patients With Liver Disease

BACKGROUND & AIMS

Patient education is critical in ensuring patient compliance and good health outcomes. Fellows must be able to effectively communicate with their patients, delivering enough information for the patient to understand their medical problem and maximize patient compliance. We created an objective structured clinical examination (OSCE) with 4 liver disease cases to assess fellows' knowledge and ability to inform standardized patients (SPs) about their clinical condition.

METHODS

We developed 4 cases highlighting different aspects of liver disease and created a 4-station OSCE: hepatitis B, acute hepatitis C, new diagnosis of cirrhosis, and an end-stage cirrhotic nontransplant candidate. The SP with hepatitis B was minimizing the fact that she could not read English. The acute hepatitis C SP was a nursing student who is afraid that having hepatitis C might jeopardize her career. The SP with the new diagnosis of alcoholic cirrhosis needed to stop drinking, and the end-stage liver disease patient had to grapple with his advanced directives. Twelve fellows from 4 GI training programs participated. Our focus was to assess the fellows' knowledge about liver diseases and the Accreditation Council for Graduate Medical Education competencies of health literacy, shared decision making, advanced directives, and goals of care. The goal for the fellows was to communicate effectively with the SPs, and acknowledge that each patient had an emotionally charged issue to overcome. The SPs used a checklist to rate fellows' performance. Faculty and the SPs observed the cases and provided feedback. The fellows were surveyed on their performance regarding the case.

RESULTS

The majority of fellows were able to successfully summarize findings and discuss a plan with the patient in the new diagnosis of cirrhosis (76.92%) and hepatitis C case (100%), but were less successful in the hepatitis B case (30.77%) and the end-of-life case (41.67%). Overall, a small percentage of fellows reflected that they did a good job (22%-33%), except at the end-of-life case (67%). The fellows' greatest challenge was trying to cover a lot of information in a single outpatient visit.

CONCLUSIONS

Caring for patients with liver diseases can be complex and time consuming. The patients and fellows' observations were discordant in several areas: for example, the fellows believed they excelled in the end-of-life case, but the SP thought only a small percentage of fellows were able to successfully summarize and discuss the plan. This discrepancy and others highlight important areas of focus in training programs. OSCEs are important to help the fellows facilitate striking the right balance of information delivery and empathy, and this will lead to better patient education, compliance, rapport, and satisfaction.

Staging a performance: learners' perceptions about direct observation during residency

CONTEXT

Evidence strongly supports that direct observation is a valid and reliable assessment tool; support for its impact on learning is less compelling, and we know that some learners are ambivalent about being observed. However, learners' perceptions about the impact of direct observation on their learning and professional development remain underexplored. To promote learning, we need to understand what makes direct observation valuable for learners.

METHODS

Informed by constructivist grounded theory, we interviewed 22 learners about their observation experiences. Data collection and analysis occurred iteratively; themes were identified using constant comparative analysis.

RESULTS

Direct observation was widely endorsed as an important educational strategy, albeit one that created significant anxiety. Opaque expectations exacerbated participants' discomfort, and participants described that being observed felt like being assessed. Consequently, participants exchanged their 'usual' practice for a 'textbook' approach; alterations to performance generated uncertainty about their role, and raised questions about whether observers saw an authentic portrayal of their knowledge and skill.

CONCLUSION

An 'observer effect' may partly explain learners' ambivalence about direct observation; being observed seemed to magnify learners' role ambiguity, intensify their tensions around professional development and raise questions about the credibility of feedback. In turn, an observer effect may impact learners' receptivity to feedback and may explain, in part, learners' perceptions that useful feedback is scant. For direct observation to be valuable, educators must be explicit about expectations, and they must be aware that how learners perform in the presence of an observer may not reflect what they do as independent practitioners. To nurture learners' professional development, educators must create a culture of observation-based coaching that is divorced from assessment and is tailored to developing learners' identities as practitioners of both the art and the science of medicine.

Objective structured clinical examination as a novel tool in inflammatory bowel disease fellowship education

BACKGROUND

Experiential learning in medical education, as exemplified by objective structured clinical examinations (OSCEs), is a well-validated approach for improving trainee performance. Furthermore, the Accreditation Council for Graduate Medical Education has identified OSCEs as an ideal method for assessing the core competency of interpersonal and communication skills. Here, we describe a novel educational tool, the inflammatory bowel disease OSCE (IBD OSCE), to assess and improve this clinical skill set in Gastroenterology fellows.

METHODS

We developed a 4-station IBD OSCE that assessed shared decision making, physician-physician communication, and physician-patient consultative skills specifically related to the care of patients with IBD. Each station was videotaped and observed live by faculty gastroenterologists. Behaviorally anchored checklists were scored independently by a faculty observer and the standardized patient/physician, who both provided feedback to the fellow immediately after each case. Post-OSCE, fellows attended a debriefing session on patient communication and were surveyed to assess their perspective on the examination's educational value.

RESULTS

Twelve second-year gastroenterology fellows from 5 fellowship programs participated in the IBD OSCE. Fellows performed well in all measured domains and rated the experience highly for its educational value. Fellows cited IBD as an area of relative deficiency in their education compared with other knowledge areas within gastroenterology.

CONCLUSIONS

To our knowledge, this is the first OSCE designed specifically for the evaluation of skills as they relate to IBD management. Using OSCEs for IBD education provides an opportunity to robustly assess core competencies and the role of the physician as an educator.