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BACKGROUND AND OBJECTIVES: Primary care teamwork has been shown to increase satisfaction and decrease stress for physicians but the impact of outpatient teamwork for primary care residents’ learning has not been described. This study aimed to understand the role of teamwork in residents’ learning during and after the establishment of teams. METHODS: Interviews with 37 primary care residents addressed their experiences at outpatient clinic, including their perceptions about whether team-based care affected their educational experience. Using qualitative thematic analysis, transcripts were coded to identify themes about teamwork and learning, both positive and negative. RESULTS: Residents described learning both about and through teamwork at continuity clinic, despite variation in the speed and extent of initial integration into teams. As residents learned how to work on a team, they realized the importance of face-to-face time together and trusting one another. Team members also taught residents about the clinical system and social aspects of patient care, as well as some procedural skills, which led them to understand how teamwork can improve patient care and efficiency. Finally, residents learned, through both optimal and suboptimal first-hand team experiences, to see team-based care as a model for future primary care practice. CONCLUSIONS: While integrating residents into primary care teams, educators should consider the potential value of teamwork as an intentional learning method. Team members, beyond the preceptor, can offer valuable instruction, and team-based workplace learning prepares residents to use teamwork to optimize care for patients.

Background In health care, hierarchy can facilitate getting work done efficiently. It can also hinder performance by suppressing valuable contributions from lower-positioned individuals. Team-based care could mitigate negative effects by creating space for all team members to contribute their unique expertise. Purpose This article sought to understand how resident-medical assistant (MA) dyads interacted before and after primary care clinics transitioned to team-based care. We also studied how they negotiated changes in interpersonal dynamics given the challenge these changes presented to hierarchical norms. Methodology We conducted two qualitative interview studies, with 37 residents and 30 MAs at primary care clinics transitioning to team-based care. Interviews were transcribed, coded, and analyzed together using a thematic networks approach and focused coding. Results An intervention that promoted teamwork prompted resident-MA dyads to change their interactions to counter traditional hierarchy. Residents increasingly asked MAs questions about patient care, and MAs initiated interactions and volunteered ideas more frequently. We also found that MAs and residents expressed some discomfort with the hierarchical ambiguity that their new interactions produced and used alternate scripts to buffer this discomfort and to collaborate as teammates despite formal hierarchy. Conclusion Among resident-MA dyads, a team-based care intervention changed interpersonal dynamics by blurring hierarchical lines and shifting traditional boundaries in ways that were uncomfortable for both groups. They were able to work around discomfort by using new scripts that downplayed the threat to hierarchy. Practice implications Organizational structures that encourage greater interprofessional collaboration may neutralize barriers that formal hierarchy in medicine can pose for effective teamwork, but this process can also bring social discomfort. Our findings suggest that health care professionals may use microlevel strategies, such as alternative scripts, to overcome formal hierarchies without openly engaging them. Together, new organizational structures and interaction techniques can help professionals work around hierarchy and improve team performance.

Little is known about how practices reorganize when transitioning from traditional practice organization to team-based care. We compared practice-level (1) configuration as well as practice- and team-level (2) size and (3) composition, before and after establishing teams. We employed a pre-/poststudy using personnel lists of 1571 to 1711 staff (eg, job licenses, titles, and team assignment) and practice manager surveys. All personnel (physician and nonphysician) worked within 18 Massachusetts academic primary care practices participating in a 2-year learning collaborative aimed at establishing team-based care. We found that establishing team-based care can involve changing practice configurations and composition without substantially changing practice size.

Educators hope that residents' experiences in primary care continuity clinics will influence more trainees to enter primary care careers. Unfortunately, evidence shows that outpatient primary care training in the United States is stressful and fails to promote primary care careers. We conducted qualitative interviews with residents to understand the source of stress and to explain this failure.In-person individual interviews were conducted with 37 primary care residents training at outpatient clinics in the US. Analysis used the constant comparative method and included open and focused coding, allowing themes to emerge inductively from the data.73% of residents interviewed reported negative emotions about clinic. Beyond stress, residents reported feeling inadequate as primary care physicians at clinic. Four factors contributed: mental distractions, unfamiliarity with primary care medicine, management of outpatients, and relationships with patients. Residents' comparisons of hospital-based and outpatient experiences favored the former in relation to the four factors.Residents feel unprepared for primary care and inadequate as primary care physicians, and these feelings discourage them from practicing primary care. This phenomenon must be studied within the entire context of residency, as residents' attitudes about their outpatient experiences were shaped in relation to their inpatient experiences.

A specific faculty development program for tutors to teach cross-cultural care in a preclinical gastrointestinal pathophysiology course with weekly longitudinal followup sessions was designed in 2007 and conducted in the same manner over a 6-yr period. Anonymous student evaluations of how “frequently” the course and the tutor were actively teaching cross-cultural care were performed. The statements “This tutor actively teaches culturally competent care” and “Issues of culture and ethnicity were addressed” were significantly improved over baseline 2004 data. These increases were sustained over the 6-yr period. A tutor's overall rating as a teacher was moderately correlated with his/her “frequently” actively teaching cross-cultural care ( r = 0.385, P < 0. 001). Course evaluation scores were excellent and put the course into the group of preclinical courses with the top ratings. Students in the Race in Curriculum Group asked that the program be expanded to other preclinical courses. In conclusion, from 2007 to 2012, a faculty development program for teaching cross-cultural care consistently increased the discussion of cross-cultural care in the tutorial and course over each year beginning with 2007 compared with the baseline year of 2004. Our data suggest that cross-cultural care can be effectively integrated into pathophysiology tutorials and helps improve students' satisfaction and tutors' ratings. Teaching cross-cultural care in a pathophysiology tutorial did not detract from the course's overall evaluations, which remained in the top group over the 6-yr period.

There is increasing recognition that team-based approaches to delivering care in ambulatory settings may be critical for improving health care services and outcomes for patients. When patients require services of nurses, social workers, pharmacists, case managers, receptionists, or schedulers in addition to their primary care providers (e.g., physicians, nurse practitioners, and physician assistants), quality and value depend on the ability of these professionals to work together in a coordinated fashion. Prior research has associated team-based primary care with improved care for patients with specific diagnoses (e.g., diabetes and depression) (Lemieux-Charles and McGuire 2006). However, findings have been mixed, given differences in the way teams were designed and implemented. Nevertheless, team-based care has become a key tenet of efforts to transform primary care practices into patient-centered medical homes (PCMHs) (The Patient-Centered Primary Care Collaborative 2007; National Committee for Quality Assurance 2014), and stakeholders are considering how to structure payments to primary care teams as opposed to individual physicians (Blumenthal et al. 2013). Despite heightened interest in improving teams and teamwork, little is known about how to assess team dynamics in ambulatory settings. While several survey instruments measure selected aspects of teamwork (e.g., conditions for team effectiveness), few tools comprehensively capture the team dynamics that evidence suggests may be valuable in ambulatory settings (Valentine, Nembhard, and Edmondson in press). Existing measures of teamwork are also either too specific (e.g., focused on geriatric care, targeted to nurses and physicians only) or not specific enough (i.e., thought applicable to any health care setting). Other surveys are designed for non-U.S. settings. Few surveys have measured, and even fewer have satisfied, standard psychometric criteria for validating surveys. A survey instrument that measures ambulatory-based team dynamics is needed because teams in these settings face challenges that are less prominent in inpatient care: high rates of patient and provider turnover, wide variation in patient needs, a need for provider coordination within and beyond facility boundaries, and increasing expectations of primary care providers to engage patients in their care. Assessing team dynamics in ambulatory settings would enable identification of team dynamics most critical for desired health care outcomes, and this would make more targeted interventions possible. To address this opportunity, we developed a novel survey that is grounded in an evidence-based conceptual model and draws on previous, psychometrically tested instruments. We administered the survey to all physician and nonphysician health care professionals caring for patients within 18 primary care practices in Massachusetts who are working to improve team-based care as part of a primary care learning collaborative. In this paper, we begin by presenting our conceptual model for how to measure team dynamics in ambulatory settings. We then describe the development of the survey instrument, explore its psychometric properties, and discuss implications for the survey, future research, and its application in ambulatory care.

Background & Aims Our study describes a faculty development program to encourage the integration of racial, cultural, ethnic, and socioeconomic factors such as obesity, inability to pay for essential medications, the use of alternative medicine, dietary preferences, and alcoholism in a gastrointestinal pathophysiology course. Methods We designed a 1-hour faculty development session with longitudinal reinforcement of concepts. The session focused on showing the relevance of racial, ethnic, cultural, and socioeconomic factors to gastrointestinal diseases, and encouraged tutors to take an active and pivotal role in discussion of these factors. The study outcome was student responses to course evaluation questions concerning the teaching of cultural and ethnic issues in the course as a whole and by individual tutorials in 2004 (pre-faculty development) and in 2006 to 2008 (post-faculty development). Results Between 2004 and 2008, the proportion of students reporting that "Issues of culture and ethnicity as they affect topics in this course were addressed" increased significantly ( P = .000). From 2006 to 2008, compared with 2004, there was a significant increase in the number of tutors who "frequently" taught culturally competent care according to 60% or greater of their tutorial students ( P = .003). The tutor's age, gender, prior tutor experience, rank, and specialty did not significantly impact results. Conclusions An innovative faculty development session that encourages tutors to discuss racial, cultural, ethnic, and socioeconomic issues relevant to both care of the whole patient and to the pathophysiology of illness is both effective and applicable to other preclinical and clinical courses.

To examine the effect of increases in payment for teaching on retention of primary care faculty, and to compare those faculty members' needs and rewards for teaching with objective data on retention.In 2006-2007, the authors compared retention rates of primary care clerkship preceptors at Harvard Medical School (1997-2006) when their stipends were raised from $600 to $900 (in 2003) and to $2,500 (in 2004), and when faculty received payment directly versus indirectly. A survey was sent to all 404 present and past living preceptors, who were asked to rank-order six factors in terms of (1) how much they needed each to continue teaching, and (2) each factor's contribution to their satisfaction with teaching.Retention rates varied from a high of 91% in 2006 to a low of 69% in 2000. Faculty were 2.66 times more likely (P.0001) to return to teach in the highest pay period than the lowest, and faculty receiving direct payment were more likely to continue teaching than those receiving it indirectly. Only 8% of the 170 responding faculty ranked receiving the stipend as the most important factor in their continuing to teach; no one ranked it first as a source of satisfaction. However, 73% ranked having a good student first as a factor in continuing to teach; 82% ranked it first as a source of satisfaction.Raising stipends was associated with increased retention, although faculty ranked stipend low in terms of what motivates them to continue teaching.

Background Team-based care is essential for delivering high-quality, comprehensive, and coordinated care. Despite considerable research about the effects of team-based care on patient outcomes, few studies have examined how team dynamics relate to provider outcomes. Purpose The aim of this study was to examine relationships among team dynamics, primary care provider (PCP) clinical work satisfaction, and patient care coordination between PCPs in 18 Harvard-affiliated primary care practices participating in Harvard's Academic Innovations Collaborative. Methodology First, we administered a cross-sectional survey to all 548 PCPs (267 attending clinicians, 281 resident physicians) working at participating practices; 65% responded. We assessed the relationship of team dynamics with PCPs' clinical work satisfaction and perception of patient care coordination between PCPs, respectively, and the potential mediating effect of patient care coordination on the relationship between team dynamics and work satisfaction. In addition, we embedded a qualitative evaluation within the quantitative evaluation to achieve a convergent mixed methods design to help us better understand our findings and illuminate relationships among key variables. Findings Better team dynamics were positively associated with clinical work satisfaction and quality of patient care coordination between PCPs. Coordination partially mediated the relationship between team dynamics and satisfaction for attending clinicians, suggesting that higher satisfaction depends, in part, on better teamwork, yielding more coordinated patient care. We found no mediating effects for resident physicians. Qualitative results suggest that sources of satisfaction from positive team dynamics for PCPs may be most relevant to attending clinicians. Practice implications Improving primary care team dynamics could improve clinical work satisfaction among PCPs and patient care coordination between PCPs. In addition to improving outcomes that directly concern health care providers, efforts to improve aspects of team dynamics may also help resolve critical challenges in workforce planning in primary care.

To evaluate the effectiveness of the Program in Palliative Care Education and Practice (PCEP), an intensive faculty development program at Harvard Medical School.PCEP is a two-week program offered annually with two on-site sessions in Boston, MA, and an interim period distance-learning component. Training integrates palliative care clinical skill development, learning theory and teaching methods, and leadership and organizational change. Longitudinal surveys (preprogram, retrospective preprogram, and postprogram) of participants from 2000-03 assessed self-reported preparation in providing and teaching palliative care; teaching and patient care practices; and satisfaction with program.The response rate was 96% (n=149) for Session I and 72% for both Session I and II (n=113). Questionnaire responses demonstrated statistically significant improvements with large effect sizes (range 0.7-1.8) on nearly all measures. Preparation increased from 3.0+/-1.1 to 4.2+/-0.7 for providing end-of-life care (1=not well prepared, 5=very well prepared), and from 2.6+/-1.0 to 4.3+/-0.7 for teaching this topic. Respondents reported behavioral changes in patient care and teaching; e.g., after the program, 63% noted that, specifically as a result of attending the course, they encouraged learners to reflect on their emotional responses to dying patients, and 57% conducted experiential exercises (e.g., role-play). Eighty-two percent rated the experience as "transformative," and many responses to open-ended items described powerful learning experiences. Participants rated the program highly (4.9+/-0.1, 1=lowest, 5=highest rating).Integrating clinical content with learning about educational methods is an efficient and effective approach to enhancing clinical faculty's capacity to model and teach clinical care. This program offers an educational model that engages practitioners, stimulates changes in practice, and offers opportunities for reflection and professional revitalization.

PURPOSE: To evaluate a faculty development program that teaches quality improvement and cost-effectiveness. METHOD: From October 2000 to February 2001, a two-part faculty development program was offered to 39 physicians from 19 U.S. medical schools supported by grants from the Partnerships for Quality Education (PQE) and Undergraduate Medical Education in the 21st Century (UME-21). Special features of the program included partnerships between academic and community physicians from each school, development of an educational innovation of interest to the participants, concurrent development of teaching skills and new medical knowledge, learning leadership skills (e.g., how to train colleagues to teach), and practice periods. The program focused on quality improvement and cost-effectiveness, but included other "managing care" topics. Prior to and after the course, participants assessed their knowledge of and competence to teach these topics, as well as other managing care topics. They also assessed their competence as medical educators and leaders. After the course, they indicated their progress in implementing their proposed educational innovations. RESULTS: Thirty-two of the 39 physicians completed evaluations both before and after the program. Self-assessed knowledge and competence to teach quality improvement and cost-effectiveness were significantly higher at the end of the course, as were all self-assessed teaching and leadership skills. The largest change scores occurred in assessments of competency to teach the new topics and to teach in new ways. Participants who implemented their innovations rated their competencies to teach quality improvement and cost-effectiveness higher than did non-implementers. CONCLUSION: Opportunities for faculty to learn how to teach a topic of stated importance to them, to practice what they have learned, and to work collaboratively with partners improved teaching skills.

OBJECTIVE: To measure the effect on patient satisfaction of medical student participation in care and the presence of medical student teaching. DESIGN: Prospective cohort study. SETTING: Eight outpatient internal medicine departments of a university-affiliated HMO in Massachusetts. PATIENTS: Two hundred seven patients seen on teaching days (81 patients who saw a medical student-preceptor dyad and 126 patients who saw the preceptor alone), and 360 patients who saw the preceptor on nonteaching days. Five hundred (88%) of 567 eligible patients responded. MEASUREMENTS AND MAIN RESULTS: Thirteen closed-response items on a written questionnaire, measuring satisfaction with specific dimensions of care and with care as a whole. Visit satisfaction was similar among patients on teaching and nonteaching days. Ninety-one percent of patients seeing a medical student, 93% of patients seeing the preceptor alone on teaching days, and 93% of patients on nonteaching days were satisfied or very satisfied with their visit; less than 2% of patients in each group were dissatisfied with their visit. Satisfaction on all measured dimensions of care was similar for patients seeing a medical student, patients seeing the preceptor alone on teaching days, and patients seeing the preceptor on nonteaching days. CONCLUSIONS: Medical student participation and the presence of medical student teaching had little effect on patient satisfaction. Concerns about patient satisfaction should not prevent managed care organizations from participating in primary care education.

To contrast prevailing behaviors and attitudes relative to prJgiary care education and practice in osteopathic and allopathic medical schools.Descriptive study using confidential telephone interviews conducted in 1993-94. Analyses compared responses of osteopaths and allopaths, controlling for prJgiary care orientation.United States academic health centers.National stratified probability samples of first-year and fourth-year medical students, postgraduate year 2 residents, and clinical faculty in osteopathic and allopathic medical schools, a sample of allopathic deans, and a census of deans of osteopathic schools (n = 457 osteopaths; n = 2,045 allopaths).Survey items assessed personal characteristics, students' reasons for entering medicine, learners' prJgiary care educational experiences, community support for prJgiary care, and attitudes toward the clinical and academic competence of prJgiary care physicians.PrJgiary care physicians composed a larger fraction of the faculty in osteopathic schools than in allopathic schools. Members of the osteopathic community were significantly more likely than their allopathic peers to describe themselves as socioemotionally oriented rather than technoscientifically oriented. Osteopathic learners were more likely than allopathic learners to have educational experiences in prJgiary care venues and with prJgiary care faculty, and to receive encouragement from faculty, including specialists, to enter prJgiary care. Attitudes toward the clinical and academic competence of prJgiary care physicians were consistently negative in both communities. Differences between communities were sustained after controlling for prJgiary care orientation.In comparison with allopathic schools, the cultural practices and educational structures in osteopathic medical schools better support the production of prJgiary care physicians. However, there is a lack of alignment between attitudes and practices in the osteopathic community.

Background: Clinical education increasingly occurs in ambulatory and primary-care practices. Physicians face increased demands for clinical productivity. Purpose: To explore whether community-based family physicians' perceptions of problems in primary-care practice affect their attitudes toward teaching. Methods: Using the national databases of the American Academy of Family Physicians, we identified a sample of family physicians who teach but are not based at academic health centers. These 80 family physicians were surveyed by telephone about their careers and their teaching. Results: The response rate was 61%. Respondents identified several problematic aspects of medical practice that may have a negative impact on teaching: administrative demands, decreasing autonomy, diminished control over conditions of practice, concern about future income, and increased productivity demands. Over three fourths of the respondents (77.5%) were concerned that increasing the amount of teaching they do would decrease the...

Background and Methods Views of managed care among academic physicians and medical students in the United States are not well known. In 1997, we conducted a telephone survey of a national sample of medical students (506 respondents), residents (494), faculty members (728), department chairs (186), directors of residency training in internal medicine and pediatrics (143), and deans (105) at U.S. medical schools to determine their experiences in and perspectives on managed care. The overall rate of response was 80.1 percent. Results Respondents rated their attitudes toward managed care on a 0-to-10 scale, with 0 defined as “as negative as possible” and 10 as “as positive as possible.” The expressed attitudes toward managed care were negative, ranging from a low mean (±SD) score of 3.9±1.7 for residents to a high of 5.0±1.3 for deans. When asked about specific aspects of care, fee-for-service medicine was rated better than managed care in terms of access (by 80.2 percent of respondents), minimizing ethical c...

The advent of new medical education (ME) journals makes evident the growth of the field of ME. However, the nature and context of growth is undefined.To analyze the evolution of publication in ME.MEDLINE retrieval using medical subject headings was used to analyze patterns of ME publications from 1960-2010: changes in number of ME publications; number of journals publishing ME articles; co-topics occurring frequently in ME articles; differences among journals' publication of co-topics.Annual publication of ME articles increased from 279 in 1960 to 3760 in 2010. 81,531 articles were published in 4208 different journals. 104 journals published ME articles in 1960, 855 in 2010. Despite an increase in journals in all fields, ME journals now account for a larger proportion of all journals indexed in MEDLINE than in 1960. One-quarter of all ME articles were indexed as internship/residency; 16% as graduate ME; 15% as undergraduate ME; and 14% as continuing ME. The five journals that published the most ME articles distinguished themselves by publishing some topics with greater or less frequency.The increase in the number of ME publications and in the number of journals publishing ME articles suggests a supportive environment for a growing field; but variation in journals' foci has implications for readers, editors and authors.

Background Team-based care has the potential to improve primary care quality and efficiency. In this model, medical assistants (MAs) take a more central role in patient care and population health management. MAs' traditionally low status may give them a unique view on changing organizational dynamics and teamwork. However, little empirical work exists on how team-based organizational designs affect the experiences of low-status health care workers like MAs. Purposes The aim of this study was to describe how team-based primary care affects the experiences of MAs. A secondary aim was to explore variation in these experiences. Methodology/approach In late 2014, the authors interviewed 30 MAs from nine primary care practices transitioning to team-based care. Interviews addressed job responsibilities, teamwork, implementation, job satisfaction, and learning. Data were analyzed using a thematic networks approach. Interviews also included closed-ended questions about workload and job satisfaction. Results Most MAs reported both a higher workload (73%) and a greater job satisfaction (86%) under team-based primary care. Interview data surfaced four mechanisms for these results, which suggested more fulfilling work and greater respect for the MA role: (a) relationships with colleagues, (b) involvement with patients, (c) sense of control, and (d) sense of efficacy. Facilitators and barriers to these positive changes also emerged. Conclusion Team-based care can provide low-status health care workers with more fulfilling work and strengthen relationships across status lines. The extent of this positive impact may depend on supporting factors at the organization, team, and individual worker levels. Practice implications To maximize the benefits of team-based care, primary care leaders should recognize the larger role that MAs play under this model and support them as increasingly valuable team members. Contingent on organizational conditions, practices may find MAs who are willing to manage the increased workload that often accompanies team-based care.

When mandated as resident competencies in 1999, systems-based practice (SBP) and practice-based learning and improvement (PBLI) were new concepts to many.To describe and evaluate a 4-week clinical elective (Achieving Competence Today-ACT) to teach residents SBP and PBLI.ACT consisted of a four-week active learning course and follow-up teaching experience, guided and supported by web-based materials. The curriculum included readings, scheduled activities, work products including an improvement project, and weekly meetings with a non-expert preceptor. The evaluation used a before-after cross-comparison of ACT residents and their peers.Seventy-eight residents and 42 faculty in 18 US Internal Medicine residency programs participated between 2003 and 2005. RESULTS AND MAIN MEASUREMENTS: All residents and faculty preceptors responded to a knowledge test, survey of attitudes, and self-assessment of competency to do 15 tasks related to SBP/PBLI. All measures were normalized to a 100-point scale. Each program's principal investigator (PI) identified aspects of ACT that were most and least effective in enhancing resident learning. ACT residents' gains in knowledge (4.4 on a 100-point scale) and self-assessed competency (11.3) were greater than controls' (-1.9, -8.0), but changes in attitudes were not significantly different. Faculty preceptors' knowledge scores did not change, but their attitudes became more positive (15.8). PIs found a ready-to-use curriculum effective (rated 8.5 on a 10-point scale).ACT increased residents' knowledge and self-assessment of their own competency and raised faculty's assessment of the importance of residents' learning SBP/PBLI. Faculty content expertise is not required for residents to learn SBP/PBLI.

In 2006-2007, Harvard Medical School implemented a new, required course for first-year medical and dental students entitled Clinical Epidemiology and Population Health. Conceived of as a "basic science" course, its primary goal is to allow students to develop an understanding of caring for individuals and promoting the health of populations as a continuum of strategies, all requiring the engagement of physicians. In the course's first iteration, topical content accessible to first-year students was selected to exemplify physicians' roles in addressing current threats to population health. Methodological areas included domains of clinical epidemiology, decision sciences, population-level prevention and health promotion, physicians' roles in the public health system, and population-level surveillance and intervention strategies. Large-group settings were selectively used to frame the relevance of each topic, and conceptual learning of statistical and epidemiologic methods occurred in conference groups of 24 students. Finally, tutorials of eight students and one or two faculty were used for critical reading of published studies, review of problem sets, and group discussion of population health issues. To help students appreciate the structure and function of the public health system and physicians' role in public health emergencies, the course included a role-playing exercise simulating response to an influenza pandemic. The first iteration of the course was well received, and assessment of students suggested mastery of basic skills. Preclinical courses represent a progressive step in developing a workforce of physicians who embrace their responsibility to improve the health of the population as a whole, as well as the health of the patient in front of them.

A study was conducted to determine whether, as the result of clinical experience in the third year of medical school and feedback on their performance from instructors, students would be able to perceive their areas of weakness, improve performance, and develop a perception of their performance that increasingly conformed to how faculty perceived them. Students evaluated their own performance in each rotation and compared their ratings with faculty ratings of them, using the same 16-item evaluation checklist. Students tended to rate themselves higher on all factors than the faculty rated them. Both faculty and students tended to give higher ratings in successive rotations, but changes in students' ratings were approximately twice those of faculty members from the first to last rotations. Students' perceptions of their performance seemed most subject to change in the areas of knowledge and management skills.

Interaction in problem-based learning (PBL) tutorials is not necessarily cooperative, which may account for variation in learning outcomes. Therefore, a cooperative assessment structure was introduced in a PBL course and the difference examined between this method and individual, lecture-based learning in mental health training. Experimental student groups gained more knowledge between pre- and post-test than did control groups, and the experimental students who scored low on the pre-test made the greatest gains. Groups that reported greater cooperation tended to have higher achievement scores. Experimental students felt that cooperation helped them learn but it also took more time and was sometimes chaotic.

Creating enduring change, both in clinician behavior and patient outcomes, is the overarching goal of continuing education in the health professions. Current methods of education and evaluation, however, often show disappointing results in achieving meaningful and lasting change among clinicians in practice.1,2 With some notable exceptions,3,4 continuing professional education programs tend to be limited in scope and method: most address narrowly defined clinical content, and most are delivered using noninteractive teaching methods that have been shown to lack effectiveness in generating learning and change.5–9 Evaluation methods also tend to be restricted in range, relying on satisfaction measures or single group, conventional pre- and postdesigns measuring short term and possibly transient outcomes, thus limiting generalizability and validity of the results.2,10–12 Improving professional education is of particular concern in the rapidly growing field of palliative care, where the need for leaders in clinical care and education far outweighs supply,13–15 and, except for full-time fellowship programs, there are relatively few educational experiences available for clinicians.3,16,17 Deficiencies in care for the dying have been well-documented,18,19 and national organizations have endorsed palliative care as a priority for training.20–29 This report describes an evaluation of the long-term impact of the Harvard Medical School Program in Palliative Care Education and Practice (PCEP), an intensive, learner-centered, interdisciplinary faculty development program that aims to build the field of palliative care by enhancing clinical expertise, pedagogic competencies, and organizational skills among a cadre of physician and nurse educators. The program is distinguished by its close integration of clinical and educational skills training, attention to the broad sweep of professional practice, including organizational change and professional development, and emphasis on affective, interactive, and relational dimensions of clinical work and teaching. In a study of short-term outcomes of PCEP, we found statistically significant improvements with large effect sizes in educational practice, attitudes, and self-reported preparation to provide and teach end-of-life care.30 Because the real merit of an educational program lies in its lasting impact on learners, we carried out a long-term follow-up of graduates, assessing preprogram, immediate postprogram, and long-term (6, 12, or 18 months) outcomes in: (1) palliative care teaching behaviors and attitudes; (2) clinical practice and self-assessed competencies; (3) palliative care program development and organizational change; and (4) professional development activities and attitudes related to palliative care.

Harvard Medical School developed a longitudinal primary care clerkship as an opportunity to teach 7 themes of modern medicine: care over time, evidence-based medicine, prevention, uncertainty, cost effectiveness, teamwork, and shared decision making.To evaluate the effectiveness of the longitudinal experience.Students followed 1 patient throughout a 9-month clerkship and integrated the 7 themes into their management plans. We coded their written reports for number and duration of student-patient encounters; characteristics of students, preceptors, sites, and patients related to encounter frequency; and integration of themes into management plans.The median number of student-patient contacts was 4.0, as was the median number of months that students maintained contact with the patients. Patients with complex diagnoses were seen more times. No characteristics of patient, student, preceptor, or site limited the number or duration of contacts. Proportions of students integrating each theme into their plans ranged from 66% (care over time) to 11% (cost effectiveness). Those who had a greater number of patient contacts integrated more themes into their plans.Longitudinal relationships with patients can be achieved with a variety of patients and drive integration of some themes.

Although competencies for managing care are often described in the medical literature, educators have been slow to integrate these competencies into clinical curricula. Backlash against managed care has created a skeptical educational environment. Many faculty feel unprepared to teach the competencies in clinical settings.From 1999 to 2001, we designed, implemented, and evaluated a faculty development program, funded by the Bureau of Health Professions, Division of Medicine. The goal of the program was to increase Undergraduate Medical Education for the 21st Century (UME-21) and Partnerships for Quality Education (PQE) faculty skills in teaching quality improvement and costeffectiveness in the clinical setting and to prepare them to teach these topics to other faculty.Thirty-nine faculty attended the 4-month faculty development program. The program, in a train-the-trainer model, consisted of two 2-day workshops as well as pre-, mid-, and end-program activities and teaching experiences. Readings, brief lectures followed by focused discussion, and active learning experiences were used to teach content, provide experience and feedback with teaching skills, and model a variety of teaching approaches.By the end of the program, participants believed that they had learned content (knowledge) and gained practical teaching skills. To be successful in effecting curriculum change around new topics, such as the managing care competencies, faculty need to not only master new content and methods but also learn how to be change agents in their schools. Because this work can be lonely, faculty need support within the school and connections with others, locally and nationally, who have similar ideas.

OBJECTIVE: To study how clinical preceptors select patients for medical student teaching in ambulatory care and to explore key factors they consider in the selection process. DESIGN: Qualitative analysis of transcribed interviews. SETTING: Harvard Medical School, Boston, Mass. PARTICIPANTS: Nineteen physicians (14 general internists and 5 general pediatricians) who serve as clinical preceptors. MEASUREMENTS: Responses to in-depth open-ended interview regarding selection of patients for participation in medical student teaching. MAIN RESULTS: Preceptors consider the competing needs of the patient, the student, and the practice the most important factors in selecting patients for medical student teaching. Three dominant themes emerged: time and efficiency, educational value, and the influence of teaching on the doctor-patient relationship. These physicians consciously attempt to select patients whose participation in medical student teaching maximizes the efficiency of the clinical practice and optimizes the students’ educational experiences, while minimizing any potential for harming the relationship between preceptor and patient. CONCLUSIONS: These findings may help validate the frustration preceptors frequently feel in their efforts to teach in the outpatient setting. Becoming more cognizant of the competing interests—the needs of the patient, the student, and the practice—may help physicians to select patients to enhance the educational experience without compromising efficiency or the doctor-patient relationship. For educators, this study suggests an opportunity for faculty development programs to assist the clinical preceptor both in selecting patients for medical student teaching and in finding ways to maximize the efficiency and educational quality of the outpatient teaching environment.

CONTEXT: It is not known whether factors associated with primary care career choice affect trainees differently at different times or stages of medical education. OBJECTIVE: To examine how role models, encouragement, and personal characteristics affect career choice at different stages (medical school vs residency) and periods (1994 vs 1997) of training. DESIGN: A split-panel design with 2 cross-sectional telephone surveys and a panel survey in 1994 and 1997. PARTICIPANTS: A national probability sample of fourth-year students (307 in 1994, 219 in 1997), 645 second-year residents in 1994, and 494 third-year residents in 1997. Of the fourth-year students interviewed in 1994, 241 (78.5%) were reinterviewed as third-year residents in 1997. MAIN OUTCOME MEASURE: Primary care (general internal medicine, general pediatrics, or family medicine) career choice. RESULTS: Having a primary care role model was a stronger predictor of primary care career choice for residents (odds ratio [OR], 18.0; 95% confidence interval [95% CI], 11.2 to 28.8 in 1994; OR, 43.7; 95% CI, 24.4 to 78.3 in 1997) than for students (OR, 6.5; 95% CI, 4.3 to 10.2; no variation by year). Likewise, peer encouragement was more predictive for residents (OR, 5.4; 95% CI, 3.3 to 8.9 in 1994; OR, 16.6; 95% CI; 9.7 to 28.4 in 1997) than for students (OR, 2.1; 95% CI, 1.3 to 3.2; no variation by year). Orientation to the emotional aspects of care was consistently associated with primary care career choice across stages and years of training. CONCLUSIONS: The effect of peer encouragement and role models on career choice differed for students and residents and, in the case of residents, by year of training, suggesting that interventions to increase the primary care workforce should be tailored to stage of training.

PURPOSE To examine changes among a nationally representative sample of students and residents in their orientations toward primary care as reflected in their attitudes toward the psychosocial and technical aspects of medicine and their perceptions of the academic environment for primary care. METHOD Confidential telephone interviews of stratified national probability samples of first- and fourth-year medical students and residents were conducted in 1994 and 1997. The 1997 survey included 219 students and 241 residents who had also been interviewed in 1994. Participants were asked about their attitudes toward addressing psychosocial issues in medicine and their perceptions of faculty and peer attitudes toward primary care. Responses were compared over time and across groups. RESULTS Between the first and fourth years of medical school, there was a decline over time in students' reported orientations to socioemotional aspects of patient care (61.6% versus 42.7%, p =.001) and their perceptions that working with psychosocial issues of patients made primary care more attractive (56.3% versus 43.5%, p =.01). This pattern continued for 1997 residents (PGY-3), who were even less likely to say that addressing psychosocial issues made primary care more attractive (26.9%). For fourth-year students in 1994 who became PGY-3 residents in 1997, there was an increased perception that non-primary-care house officers and specialty faculty had positive attitudes toward primary care (20.8% versus 33.0%, p =.005; 28.3% versus 45.7%, p

To evaluate the long-term effects of an innovative curriculum, the New Pathway (NP) Program, on behaviors and attitudes related to humanistic medicine, lifelong learning, and social learning.Long-term follow-up of Harvard Medical School students who participated in a randomized controlled trial. Descriptive study using 1998 telephone interviews of 100 1989 and 1990 graduates (50 who had studied the NP curriculum, 50 who had studied the traditional curriculum). The NP Program consisted of problem-based learning tutorials, with coordinated lectures, labs, experiences in humanistic medicine, and clinical experiences; the traditional program consisted of basic science lectures and labs.Of 22 measures on the survey, NP and traditional students differed significantly on only five (three humanism; two social learning): 40% of NP students and 18% of traditional students went on to practice primary care or psychiatry. NP students rated their preparation to practice humanistic medicine higher than did traditional students and expressed more confidence in their ability to manage patients with psychosocial problems. NP students were more likely than were traditional students to believe that faculty from the first two years continued to influence their thinking. NP students liked the pedagogic approaches of their program more than traditional students did. There was no difference between the groups on measures of lifelong learning.Differences between NP and traditional students in the humanism domain first appeared during medical school and residency and remained significant well into practice, suggesting that humanistic medicine can be taught and learned.

Factors associated with the intention to practice primary care were examined in a survey of a national sample of PL-2 residents (n=98). Socioemotional orientation (nature), faculty and peer encouragement (nurture), and clinical experiences during residency (nurture) were independently associated with a primary care career choice. For residents who changed career intentions to primary care from a nonprimary care preference, gender, encouragement by faculty and peers, and outpatient experiences during residency were associated with the change. Encouragement by both faculty and peers had the strongest influence on primary care career choice for all residents.

The authors evaluated the reliability of the proposal review process used by a faculty-student committee to choose medical student researchers for summer fellowships. A total of 82 proposals were reviewed by the committee over a two-year period (43 in 1987 and 39 in 1988); the proposals were assigned ratings in the spring of each year. The 39 students whose proposals received the highest ratings over the two-year period received fellowships and carried out their projects during ten weeks in the summer of each year. In December of both years, the research fellows, along with a total of 12 students whose proposals had been rejected by the program over the two-year period but who had received support from other programs, presented their findings. These research presentations were also judged and rated, and the ratings of all the presentations were compared with the student committee's original ratings of the research proposals. A significant correlation was found between both years' sets of ratings for the proposals and the research presentations. The "accepted" students generally received higher ratings on their presentations than did the "rejected" students; however, the mean of the ratings received by the "accepted" students for their presentations was not significantly higher than that received by the "rejected" students. Even so, the significant correlation between each year's set of ratings for all the students involved demonstrates the soundness of the review process.

Despite barriers of limited time and lack of formal preparation for teaching, physician-teachers want to do a good job in the classroom. However, without appropriate feedback or self-reflection, physician-teachers have no systematic way to think about their role both in what students learn and in how well they understand important information. With this in mind, the authors developed a model, the Teaching Matrix, designed to encourage clinician-teachers to reflect on their teaching before, during, and after each teaching session. The Matrix helps teachers to address five central questions: Who am I teaching? What am I teaching? How will I teach it? How will I know if the students "got it"? And how will I improve my teaching for the next time? In this paper, the authors describe how the Teaching Matrix may be used as a tool for planning actions, as a "suggestion box" of ideas, advice, and questions, and, most importantly, as a guide to systematic reflection on teaching.

The primary care clerkship (PCC) at Harvard Medical School was established in 1997. The goals are to provide students with longitudinal experiences with patients and to include modern themes in the curriculum: managing illness and clinical relationships over time; finding the best available answers to clinical questions; preventing illness and promoting health; dealing with clinical uncertainty; getting the best outcomes with available resources; working in a health care team; and sharing decision making with patients. The PCC, a required course in the clinical years, meets one afternoon a week for nine months. Students spend three afternoons per month in primary care practices, where they see three to five patients per session and follow at least one patient ("longitudinal patient") over time. Classroom sessions, in both large- and small-group formats, promote a common educational philosophy and experience, and reinforce habits of problem-based learning established in the preclinical years. The students rated 74% of their preceptors excellent, especially praising their ability to facilitate and support good interpersonal relationships with patients, their ability to encourage students' independent evaluation of patients (as opposed to shadowing), and their enthusiasm for teaching. Students saw their longitudinal patients a mean of 4.8 times; 83% saw their patients at least three times. The PCC complements the curriculum of block clerkships in hospitals, and because the two are offered concurrently, students are required to come to terms with two substantially different cultures within medicine. Other medical schools are beginning to develop longitudinal clerkships to ensure that students have essential educational experiences that are difficult to achieve in block, hospital-based clerkships.

Objective. —To describe the attitudes toward and perceptions of primary care education and practice among academic health center constituents. Design and Participants. —Descriptive study using confidential telephone interviews (October 1993 to March 1994) of national stratified probability samples of first- and fourth-year medical students, residents, clinical faculty, internal medicine and pediatrics residency training directors and chairs, and deans (N=2293). Results. —Five areas were examined: respondents' specialty orientation, attitudes toward the competence of primary care physicians, encouragement and positive regard for primary care, exposure to primary care-related educational experiences, and socioemotional orientation. The response rate was 84%. Respondents generally perceive primary care tasks as not requiring high levels of expertise; nearly half believe that generalists are not the best physicians to manage patients with serious illness and that the quality of primary care research is inferior to that in other fields. Attitudes are more positive toward the quality of primary care teaching. Learners perceive little encouragement for generalist careers and negative attitudes toward generalists among faculty, and view the quality of their primary care training as inferior to that for specialty practice. Those who have progressed further in the academic medicine hierarchy generally report lower levels of socioemotional orientation than individuals at earlier phases of career development. Conclusions. —Despite changes in the health care system and in education, students and residents encounter an atmosphere that is chilly toward primary care. If medical educators seek to optimize enthusiasm and preparation for primary care careers, they must develop approaches to changing the attitudes, values, and composition of their faculties.

In a five-year study of medical students who had participated in a first-year elective course on cancer, the authors found that 47 percent of all participants subsequently became involved in other cancer programs. A sample (n = 40) of the participants was interviewed and studied in depth. Their subsequent expressed and overt interests in cancer were related to their achievement on neoplasm-related test items contained in second-year systemic pathology examinations and to their perception of transfer of learning from the cancer course. Neither expressed nor overt interest in cancer was significantly related to test scores on neoplasm items; but perceived transfer of learning was positively related to scores on neoplasm items, and perceived transfer and overt interest, combined, significantly related to test scores on neoplasm items in systemic pathology.

We believe the focus and emphasis of this committee on informed consent is unique, and that the development of an informed consent teaching process for residents will focus on the moral and ethical issues regarding informed consent. Even more important, we believe we will emphasize the patient care aspects of informed consent and also teach residents their responsibilities for long-term patient care with regard to patients' satisfaction and understanding of their disease process.

The long-term effects of a first-year medical school course in disease prevention focusing on cancer were studied. The authors hypothesized that students' increased knowledge of disease prevention principles would result in more positive attitudes toward aggressive treatment and prevention of cancer and a more frequent use of disease prevention techniques in clinical settings. On two occasions one to three years after the course, groups of students who took the course and groups that did not take the course responded to a test of knowledge of cancer, a cancer attitude survey, a clinical practice survey, and an evaluation of the course's relevance. Also, their clinical behavior was observed and coded during videotaped interviews of patients. While the students who took the course were more knowledgeable about cancer than their peers who did not, they did not have significantly more positive attitudes; nor were they significantly more likely to use prevention techniques in clinical settings. However, the more knowledgeable students--both those who took the course and the control students--had more positive attitudes than the less knowledgeable students. Those students who considered the course relevant to their training were more knowledgeable and had more positive attitudes toward cancer prevention than those who did not consider it relevant.