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    (2014-03) Elrod, Shara; Bullock, Katura
    Purpose Objective structured clinical examinations (OSCEs) are organized, multi-station activities designed to allow students to demonstrate their ability to perform specific clinical skills. OSCEs are increasingly being used in health professions education to objectively evaluate performance-based abilities. Observing and grading OSCEs is a key responsibility of persons who serve as raters. However, there is a surprising dearth of information on validated techniques of OSCE rater training. The objective of this project was to develop and validate a rater training process based on Kilpatrick’s 4 levels of evaluation and which maximizes inter-rater reliability of performance-based OSCE assessment across the University of North Texas System College of Pharmacy (UNT SCP) curriculum. Methods The UNT SCP curriculum includes a four-semester sequence of Pharmacy Practice Skills Labs. Each semester contains at least one OSCE to evaluate performance-based abilities. A training process for raters of interactive OSCE stations was developed. The OSCE rater training included both clinicians and standardized patients. The training was comprised of group discussion of the standards and their meaning, instruction on completing clinical checklists and global impression scales, common sources of systematic rater error, and practice scoring sample videos. Due to varying schedules and distance from campus, the training included both online and live segments. All raters were asked to view a sample recorded encounter of each interactive station. Standardized patients provided a global impression scale. Clinicians completed a binary checklist to provide a numerical grade and a pass/fail designation in addition to the global impression scale. Raters were asked to complete a pre- and post-training survey via Likert scale (1=strongly disagree; 4 = strongly agree; 0 = not applicable) and training outcomes were assessed using Kirkpatrick’s 4 levels of evaluation. Results Of the 13 raters surveyed (10 clinicians; 3 standardized patients), four raters (31%) completed the pre-training survey and 6 raters (46%) completed the post-training survey. Raters were asked about their knowledge of OSCE philosophy and structure, common sources of rater error, their ability to use objective clinical skills-based checklists and global impression scales, and their confidence in developing consensus standards for grading. As expected, median likert-scale scores improved from the pre-training (1.0) to the post-training survey (4.0). Data detailing inter-rater reliability is forthcoming. Conclusions In this pilot training program, UNT SCP OSCE raters had overall increases in their knowledge and ability to objectively evaluate pharmacy students in this 1st year Pharmacy Practice Skills Lab. These results support the need for increased focus on OSCE rater training programs.
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    (2014-03) Dolan, Kathryn J.
    Purpose (a): The Medical Home Model as implemented within the guidelines of the Affordable Care Act, requires physicians to utilize community resources provided by many diverse allied health professions and organizations, including social, vocational and rehabilitation service providers which are typically “outside of the four walls” of the medical home. This research addresses approaches to enriching the curriculum to introduce students to the competencies required for community and/or systems based practice, many addressed in the NBOME Domain 7 Competency—Systems Based Practice. In the rapidly changing practice environment, osteopathic medical students need to be prepared for interprofessional practice during their clinic training. Methods (b): Educational objectives for IPE outside the four walls are identified. Varying instructional strategies to meet these objectives are identified and evaluated taking into account their costs, benefits and challenges. Many professionals from diverse allied health professions and organizations are keenly aware of the barriers their clientele face in accessing the care they need and communicating those needs to physicians. Comparison are made between two basic approaches to systematically expose medical students to other members of the extended health care team, a large classroom format where all students are exposed to the same material, and individual or small group visits to specific agencies chosen by the students. Results (c): Student evaluations, performance on quizzes and focus group feedback reveal strengths and weaknesses of these approaches. Large group presentations by community professionals is by far the most efficient delivery method, however is most effective when case studies are used to illustrate the needs and barriers accessing services their clients face. Student focus group feedback led to developing a format that can be applied to diverse agencies and client populations. Individual and small group visits with community agencies are typically rated very favorably by students, however do not offer consistent experiences that meet all learning objectives. Conclusions (d): Recommendations are made for best practices and further development. Medically vulnerable and underserved individuals present with health problems that are deeply embedded in social, economic, community and psychological conditions which must be addressed for successful treatment outcomes. In Accountable Care Organizations (ACO), there will be a need for all practitioners to be able to respond appropriately to a broad array of these common situations and the challenges they pose. Medical students entering training in ACO practice environments will be well served to know how to recognize the needs of medically underserved and vulnerable patients, identify their problems, barriers they experience, and locate appropriate community services “outside of the four walls” of the medical home.
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    (2014-03) Lane, Yolanda; Smith, Raina; Knebl, Janice; Marquez-Hall, Sandra; Eshon, Constance
    This research study identified and evaluated the attitudes and confidence level of medical students’ knowledge, skills, and perceptions related to the health care of older adults. A survey was administered as a pre-test during first year orientation and then as a post-test after student exposure to a total of 163 hours of geriatric curriculum in Y1 and Y2. Information gained from this research could improve the development and delivery of medical education curriculum related to provision and care of older adults. Purpose (a): Between 2005 and 2030, the number of adults in the US aged 65 and older will almost double from 12% to almost 20% of the population, with those who are 80 and over, “the oldest old” expected to nearly double from 11 million to 20 million. This group, along with changes in the US Health Care System, will place increased demand on the patchwork of health care services due to the epidemic of chronic disease such as dementing disorders, arthritic conditions, diabetes, hypertension, and heart disease. The Reynolds Geriatric Education & Training in Texas (GET-IT) Program sought to better address the medical needs of the growing geriatric population. The two objectives of the study were: 1) Increase the content of geriatric education in the medical education curriculum; a total of 163 hours of geriatric education were added to Y1 and Y2; and, 2) Identify and evaluate the attitudes of student perceptions related to the health care of older adults in response to the geriatric curricular content. Methods (b): The study used a 52 item questionnaire Aging and Healthcare Survey Medical Students Perceptions that contains a 5-point Likert Scale for measurement. Surveys were administered twice over a three year period (2009-2011); once at orientation as a pre-test and again as a post-test at the end of Y2 after medical students were exposed to geriatric curriculum and the SAGE Program. A selected sample of surveys (n=95) were used for this review. Results (c): Only responses that contained significance at p ≤ 0.005 related to changes in student perceptions of aging and healthcare between Y1 and Y2 of medical school were included in this report. Selected Survey Items from Aging & Healthcare Study. 5= Strongly Agree; 4= Agree; 3= Neutral; 2= Disagree; 1= Strongly Disagree. Year 1 Mean. Year 2 Mean. P-value. Q14 There is not enough course content on the evaluation and care of older adults. 4.44. 2.70. < .001. Q21 I am comfortable talking with an older patient about their death. 4.20. 3.59. < .001. Q23 Physicians need to learn special skills to care for older patients. 4.23. 3.75. < .001. Q30 Learning about how to care for older patients should be a priority for people in Medicine. 2.53. 3.40. < .001. Q31 I know a lot about growing older. 2.12. 3.06. < .001. Q38 I would prefer not to provide medical care to older adults. 3.37. 2.52. < .001. Q29 Physicians need to understand issues of quality of life for an older adult. 3.03. 4.05. 0.002. Q16 As people become older, most become depressed. 3.19. 2.75. 0.004. Conclusions (d): Our findings showed some mixed results. Exposure to the geriatric curriculum had a positive impact on student’s awareness, understanding, and treating of older adults including psycho-social awareness. Students reported more confidence in and an appreciation of the need for communication with older adults in the areas medical history and quality of life issues but less confidence with older adults in areas of palliative care and end of life issues. The data obtained from the survey supports the integrative model of geriatrics curricula into undergraduate medical education.
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    (2014-03) Joseph, Ryan; Wagner, Russell; Webb, Brian
    The purpose of this study is to evaluate if the operative experience level of residents affects the incidence of ligament injuries in patients who have received a total knee arthroplasty. Purpose (a): The focus of this study was to evaluate intraoperative errors in the performance of total knee arthroplasties (TKAs) and compare the error rate of when a junior resident versus a senior resident served as the primary surgeon. Methods (b): A restrospective analysis was performed on all of the TKAs performed by either a junior or senior resident, directly supervised by Russell Wagner, MD, over a four year period of time. This study identified 346 cases, 143 of which were performed by a junior resident and 203 of which were performed by a senior resident. Incidence of injury was also evaluated to determine if intraoperative errors occur as frequently throughout a given rotation or if the occurrences decreased as the rotation progressed. In addition to this, differences between rotations taking place at the beginning of the year and rotations occuring at the end of the year was also investigated. Finally, the last factor analyzed was whether there was a correlation between a patient’s BMI and a ligament injury. Results (c): Of the 346 total knee arthroplasties performed from January 1, 2008 to December 31, 2012, there was an incidence of ligament injury in 7.5% of the cases. The occurrence of injury in which junior residents performed the surgery was 6.3%, compared to 8.3% when senior residents performed the surgery. There were no significant differences between junior or senior residents performing the surgery with regards to intraoperative ligament or tendon injury (p=. 58). The most common ligament injured was the medial collateral in 11 (3%); other ligament injuries included the posterior cruciate ligament in 10 (3%), the patellar tendon in 3 (1%), the popliteus tendon in 2 (.5%), and the lateral collateral ligament and iliotibial band in 1 (.3%). There was no relationship between ligament/tendon damage and in which month of the rotation the surgery was performed. There was also no correlation between rotations during the beginning versus the end of the year. 1 ligament/tendon injury occurred in 89 patients (1%) with a BMI of 30 or less while 25 ligament/tendon injuries occurred in 257 patients (10%) with a BMI of more than 30. This difference was statistically significant (p=.034). Conclusions (d): This analysis suggests that supervised junior residents may safely play a more active role when performing total knee arthroplasty since their involvement is not associated with increased intraoperative ligament or tendon injury. This information may assist attending orthopaedic surgeons and resident training programs in determining the role of junior residents during surgery.