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Biomedical subjects

L Pangaro

Publications and source records attributed to L Pangaro.

15 recordsLinked to original sources
PubMed2003

Core problems reported by students in a palm OS and Internet-based problem entry system predicts performance on the third-year internal medicine clerkship.

CWeblog is a web and palm OS-based system used by medical students to record the problems and diagnoses of patients encountered in third-year clerkships at the Uniformed Services University. Data is available for analysis by clerkship directors as soon as it is entered. A pretest is given on the first day of the internal medicine third-year clerkship (the clerkship), and the National Board of Medical Examiners shelf examination (NBME) is given during the final twelfth week. Internal medicine specialty societies publish a list of 20 core problems in internal medicine to be emphasized during the third-year clerkship.

Clinical Clerkship↗
PubMed2001

Effect of clinical teaching on student performance during a medicine clerkship.

PURPOSE: To measure what proportion of student clerkship performance can be attributed to teachers' educational skills as reported by students. SUBJECTS AND METHODS: From August 1992 to June 1994, we collected critiques of teacher skills from 314 third-year students at the end of a 12-week medicine clerkship. Interns, residents, attending physicians, and student preceptors were rated (on a 1 to 5 scale) on teaching behaviors from the 7 categories of the Stanford Faculty Development Program framework. A linear regression model was used to determine the relative contributions of the rated teaching behaviors in predicting final student performance and improvement across the clerkship ("student growth"), measured using end-of-clerkship variables (clinical grades, National Board of Medical Examiners medicine shelf examination, practical laboratory examination, and an analytical essay examination) and preclerkship variables (pre-third-year grade point average [GPA], United States Medical Licensing Examination, Step I, and clerkship pretest). RESULTS: Data were available for 293 (93%) of 314 students, who completed a total of 2,817 critiques. The students' preclerkship GPA accounted for the greatest percentage of variance in student performance (28%, P < 0.0001). Clinical teaching behaviors accounted for an additional 6% (P < 0.0001) of the variance. For student growth across the clerkship, teaching accounted for 10% of the variance (P < 0.0001). Among the 7 Stanford educational categories, teaching behaviors promoting control of session (r2 = 5%, P = 0.0002) and fostering understanding and retention (r2 = 4%, P = 0.001) had the greatest effect. The resident had the most effect on student growth (r2 = 6%, P = 0.0001) when compared with other teaching levels. Teaching had a greater effect on growth for students with preclerkship GPA above the mean (16% versus 6%), for older students (24% versus 7%), and for students with a nonscience undergraduate degree (33% versus 9%). CONCLUSION: The preclerkship GPA, reflecting 2 years of work, was the most important predictor of student performance. Teaching behavior, as measured by student assessments, also affected student performance.

Adult↗
PubMed2000

Using formal evaluation sessions for case-based faculty development during clinical clerkships.

Developing housestaff and faculty in their roles as medical educators is a dynamic process. The rigorous clinical evaluation method used during the third-year internal medicine clerkship at the Uniformed Services University uniquely incorporates faculty development into the process of evaluation and generating feedback for students. Formal evaluation sessions are held monthly at all clerkship sites throughout the 12-week clerkship and are moderated by either the internal medicine clerkship director or the on-site clerkship directors. Although designed to provide an opportunity for faculty to evaluate student performance and prepare formative feedback, the sessions also function as formal, planned, and longitudinal forums of "real-time," "case-based" faculty development that address professional, instructional, and leadership development. The evaluation sessions are used as a means to model and teach the key concepts of the Stanford Faculty Development Program. Providing a unifying form of evaluation across multiple teaching sites and settings makes formal evaluation sessions a powerful, state-of-the-art tool for faculty development.

Case-Control Studies↗
PubMed1999

What learners and teachers value most in ambulatory educational encounters: a prospective, qualitative study.

PURPOSE: To determine what learners and teachers value most in ambulatory learning encounters and whether the choices of the two groups are in concordance. METHOD: In 1996, the authors surveyed learners and teachers at a walk-in clinic immediately after each of 103 consecutive learning encounters. The participants answered two open-ended questions: (1) What was the one most valuable aspect of this learning encounter? and (2) List one thing that would make it better. Using qualitative analysis methods, two raters categorized the responses; their agreement was substantial (kappa = .75). RESULTS: Half the responses fit five categories: diagnosis (15%), general management (14%), physical examination skills (9%), patient selection (6%), and time issues (6%). The participants most valued general exposure to diagnosis (29%) and general management issues (29%). Regarding their suggestions for improving the encounters, 33% cited structural issues (often "more time"), while 43% had no suggestions ("nothing" or "fine as is"). Substantial concordance existed between the rankings by category of the teachers' and learners' comments, but (1) learners were more likely to rate the educational value of the encounter excellent or very good (64% vs 47%, p < .01); (2) teachers were more likely than medical students (but not interns) to place the most educational value on the physical examination (30% vs 4%, p = .001); and (3) agreement on what was most valuable in any individual encounter was poor (kappa = .03). CONCLUSIONS: In evaluating ambulatory educational encounters, learners and teachers placed highest value on general exposure to diagnosis and disease management; while the most commonly recommended changes related to structural issues, particularly inadequate time. While learners and teachers agreed in general on the relative ranking of teaching activities, they often found different things to be educationally salient in a particular encounter.

Ambulatory Care↗
PubMed1999

A comparison of outcomes for walk-in clinic patients who see interns and those who see staff physicians.

PURPOSE: To collect pilot data on the effect of interns' involvement on patient care outcomes. METHOD: Between January 1995 and August 1998, 750 patients at a walk-in clinic completed pre-visit questionnaires on symptom-related expectations and functional status. Three follow-up surveys (immediately after the visit, at two weeks, and at three months) assessed symptom outcomes, satisfaction, illness worry, and unmet expectations. Physicians were surveyed about their perceptions of the "difficulty" of each patient encounter. RESULTS: During the study period, 195 patients (26%) were seen by interns and 555 (74%) by staff physicians. The patient groups did not differ in illness worry, unmet expectations, or satisfaction immediately after the visit, at two weeks, or at three months. Patients seen by interns were more satisfied with the time they had spent with their clinicians (p = .007). Interns were more likely to experience their patient encounters as difficult. There was no difference in visit costs, subspecialty referrals, health utilization, or hospitalization rates. CONCLUSION: Patients who are seen by interns in an ambulatory clinic are similar to those who are seen by staff physicians in terms of post-visit satisfaction, residual expectations, symptom resolution, and functional status improvement.

Ambulatory Care Facilities↗
PubMed1999

A new vocabulary and other innovations for improving descriptive in-training evaluations.

Progress in improving the credibility of teachers' descriptive evaluations of students and residents has not kept pace with the progress made in improving the credibility of more quantified methods, such as multiple-choice examinations and standardized patient examinations of clinical skills. This article addresses innovative approaches to making the ongoing in-training evaluation (ITEv) of trainees during their clinical experiences more reliable and valid. The innovations include the development of a standard vocabulary for describing the progress of trainees from "reporter" to "interpreter" to "manager" and "educator" (RIME), the use of formal evaluation sessions, and closer consideration of the unit of clinical evaluation (the case, the rotation, or the year). The author also discusses initial results of studies assessing the reliability and validity of descriptive methods, as well as the use of quantified methods to complement descriptive methods. Applying basic principles--the use of a taxonomy of professional development and statistical principles of reliability and validity--may foster research into more credible descriptive evaluation of clinical skills.

Clinical Competence↗
PubMed1998

Internship ratings as a validity outcome measure for an evaluation system to identify inadequate clerkship performance.

PURPOSE: To determine whether a third-year clerkship evaluation system validly predicted students' later performance ratings during their internships. METHOD: Adequacy of students' clerkship performances and the need for remediation were determined during seven consecutive academic years at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine using a criterion-based process including formal evaluation sessions. Internship ratings of students who needed remediation (remediators) from 1986 to 1993 were compared with those of students who voluntarily chose fourth-year medicine (non-remediators). Using written questionnaires, internship directors rated the graduates on a five-point scale for fund of knowledge, attitude, and analytic ability, and also provided written comments. RESULTS: Responses to questionnaires were available for 75 of 97 remediators (78%) and 268 of 313 non-remediators (86%). The remediators were 12.9 times more likely to have low internship performance scores and 9.4 times more likely to receive unfavorable comments than were the non-remediators. However, the majority of the remediators (80%) received only favorable comments. The medicine clerkship grade was more sensitive than the non-medicine grade-point average in predicting problems during internship (75% vs 8%). CONCLUSION: The medicine clerkship evaluation process detected whether a student was likely to have problems during internship, and the internship ratings supported the predictive validity of the evaluation system. The majority of students who were successfully remediated had no identifiable problems during internship.

Clinical Clerkship↗
PubMed1997

The effectiveness of formal evaluation sessions during clinical clerkships in better identifying students with marginal funds of knowledge.

PURPOSE: To compare evaluation methods for identifying third-year medical students whose funds of knowledge are marginal. METHOD: The written evaluation forms and comments from a formal evaluation session for 124 students in the inpatient medicine clerkship in 1992-93 at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine were reviewed. The written and verbal ratings of a student's general fund of knowledge were converted to similar five-point categorical scales. For each evaluation method, chi-square analysis was used to compare the students identified as having marginal funds of knowledge with those who scored < or = 300 on the end-of-clerkship NBME subject examination. RESULTS: Sixteen students scored < or = 300 on the NBME subject examination. For the checklist descriptors, ratings of "marginal" identified three of these 16 students (a sensitivity of 19%). For the written comments on the evaluation form, ratings of "marginal" identified four of the 16 (a sensitivity of 25%). For the formal evaluation session, however, ratings of "marginal" identified seven of the 16 (a sensitivity of 44%). The specificity of a "marginal" rating was excellent (> or = 95%) for all three evaluation methods. Chi-square analysis was significant for each method (p < or = .01). CONCLUSION: Although the ability of housestaff and faculty to identify students with weak funds of knowledge may be less than ideal, it may be improved by the routine use of a formal evaluation session. If done during the clerkship, this would allow for a specific plan of remediation to be designed with the instructors for the students at risk.

Chi-Square Distribution↗
PubMed1995

A prospective, randomized trial of a six-week ambulatory medicine rotation.

BACKGROUND: Medical schools are placing increased emphasis on training students in the ambulatory setting, but few studies show the benefit or academic risk of such innovation. The authors studied the effect of such a new rotation with a rigorous study design. METHOD: From a group of 166 third-year students at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine assigned in 1990-91 to do six weeks of their third-year medicine clerkship at Walter Reed Army Medical Center, 106 volunteers were randomized to six weeks either on the usual rotation on the general medicine wards (69 students) or to a new ambulatory rotation (37 students). Multiple pre- and postclerkship parameters were used to evaluate clerkship skills and knowledge; eventual internship choice was determined. RESULTS: The randomization was successful. Postclerkship performances were the same in (1) the medicine subject examination of the National Board of Medical Examiners, (2) a multiple-choice test in interpreting laboratory results, (3) blinded rating by an expert panel of the quality of final written histories and physical exams, (4) blinded rating by an expert panel of the students' written case analyses of their own patients, and (5) a written multiple-step examination of problem-solving ability. Any differences between groups favored the ambulatory group. An increase in choice of primary care internships among students randomized to the ambulatory rotation was not significant. CONCLUSION: It is possible to study innovative rotations using a prospective, randomized design. Substituting a six-week block ambulatory experience for a ward rotation did not decrease students' abilities to write up or analyze complex cases.

Ambulatory Care↗
PubMed1994

Third-year medical student attitudes toward internal medicine.

BACKGROUND: Student attitudes offer insight into career decisions and may suggest causes of the diminished interest in internal medicine. Students entering a salaried managed health care environment may have different attitudes about careers and potential income. Additionally, we evaluate the effect of an ambulatory experience on student attitudes and career selection. METHODS: We surveyed 163 medical students from the Uniformed Services University of the Health Sciences, Bethesda, Md, at the successful completion of the third year to determine their attitudes regarding the work, lifestyle, prestige, patient type, and challenge of internal medicine, as well as primary care interest, and the importance of income in career selection. A subgroup of 107 volunteers was randomized to either the traditional internal medicine clerkship (n = 69), or to 6 weeks of ambulatory medicine and 6 weeks of ward medicine (n = 38). RESULTS: The selection rate was low for internal medicine (10%) and was high for family practice and transitional internships (37%). Although most students highly valued their internal medicine training, relatively few selected internal medicine as a career. Students saw chronic illness and type of work, but not lifestyle, as disincentives toward choosing an internal medicine career. Half of the students believed that income potential would be a major factor in attracting students into internal medicine, and that reimbursement should be shifted from procedural fields to primary care. The ambulatory clerkship did not affect student attitudes nor type of internship selected. CONCLUSIONS: Medicine clerkships, whether traditional or ambulatory, are highly valued educational experiences yet may be insufficient by themselves to attract students to an internal medicine career. Income potential remains an important concern in the setting of salaried managed care, even for students who lack financial debt.

Adult↗
PubMed1994

A controlled trial of a seminar to improve medical student attitudes toward, knowledge about, and use of the medical literature.

OBJECTIVE: To determine whether an interactive seminar could affect medical student knowledge of research design, basic critical appraisal skills, and attitudes toward and clinical use of the medical literature. DESIGN: Controlled, nonrandomized clinical trial. PARTICIPANTS: Third-year clinical clerks (n = 146) during their core medicine clerkship. INTERVENTIONS: Two 90-minute interactive seminars. MEASUREMENTS AND MAIN RESULTS: Pre- and postquestionnaires were used to assess knowledge and attitudes regarding the use of the medical literature among 65 study and 81 control students. Blinded review of write-ups assessed actual use of the medical literature. Overall, 80% of the students subscribed to one or more journals and reported reading three or more journal articles per month. After the intervention, the study students were more likely than the control students to consider: 1) study design important in article selection and 2) use of medical literature critical to patient care decisions. Knowledge scores were significantly improved in the study group (p = 0.0001). The intervention yielded no increase in the actual use of medical literature in patient write-ups over that encouraged by usual clerkship goals. 51% of the study and 48% of the control students cited literature at baseline, and 53% of all the students did so after the intervention. Of these citations, 50% were for journal articles and the remainder were for textbooks. The students infrequently mentioned the quality of the cited literature. CONCLUSIONS: An interactive seminar designed to introduce medical students to critical appraisal improved student knowledge and attitudes but did not increase the actual use of literature in patient write-ups.

Adult↗