Faculty Bibliography

INTRODUCTION: Special concerns often arise when medical students are themselves the subjects of education research. A recently completed large, multi-center randomized controlled trial of computer-assisted learning modules for surgical clerks provided the opportunity to explore the perceived level of risk of studies where medical students serve as human subjects by reporting on: 1) the response of Institutional Review Boards (IRBs) at seven institutions to the same study protocol; and 2) the thoughts and feelings of students across study sites about being research subjects. METHODS: From July 2009 to August 2010, all third-year medical students at seven collaborating institutions were eligible to participate. Patterns of IRB review of the same protocol were compared. Participation burden was calculated in terms of the time spent interacting with the modules. Focus groups were conducted with medical students at each site. Transcripts were coded by three independent reviewers and analyzed using Atlas.ti. RESULTS: The IRBs at the seven participating institutions granted full (n=1), expedited (n=4), or exempt (n=2) review of the WISE Trial protocol. 995 (73% of those eligible) consented to participate, and 207 (20%) of these students completed all outcome measures. The average time to complete the computer modules and associated measures was 175 min. Common themes in focus groups with participant students included the desire to contribute to medical education research, the absence of coercion to consent, and the low-risk nature of the research. DISCUSSION: Our findings demonstrate that risk assessment and the extent of review utilized for medical education research vary among IRBs. Despite variability in the perception of risk implied by differing IRB requirements, students themselves felt education research was low risk and did not consider themselves to be vulnerable. The vast majority of eligible medical students were willing to participate as research subjects. Participants acknowledged the time demands of their participation and were readily able to withdraw when those burdens became unsustainable.

BACKGROUND: Stress, depression, and suicide are universal but frequently unrecognized issues for women and men in residency training. Stress affects cognitive and psychomotor performance both inside and outside of the operating room. Stress impairs the 2 key components of a surgeon's responsibilities: intellectual judgment and technical skill. We hypothesized that the recognition of depression, substance abuse, failing personal relationships, and potential suicide is poor among surgeons. If residents can recognize the signs of stress, depression, and suicide among colleagues, we believe it will not only improve their quality of life but also may preserve it. METHODS: We first determined baseline resident knowledge of the signs of surgical stress including fatigue; burn out; depression; physician suicide; drug and alcohol abuse; and their effects on family, friends, and relationships. We then developed a curriculum to identify these signs in first, second, third, and fourth year surgical residents were identified as the target learners. The major topics discussed were depression; physician suicide; drug and alcohol abuse; and the effects of stress on family, friends, and our goals. Secondary objectives included identifying major sources of stress, general self-awareness, understanding professional choices, and creating a framework to manage stress. Residents participated in an interactive seminar with a surgical facilitator. Before and after the seminar, a multiple-choice test was administered with questions to assess knowledge of the signs of stress (eg, fatigue, burn out, and depression). RESULTS: Twenty-one residents participated in this study. Seventeen completed the pretest, and 21 participated in the interactive seminar and completed the post-test. The pretest revealed that surgical residents were correct in 46.8% (standard deviation [SD] = 25.4%) of their responses. The postseminar test showed an improvement to 89.7% (SD = 6.1%, P < .001, paired Student t test = 5.37). The same test administered 4 months later to 17 of the 21 learners revealed 76.9% (SD = 18.7%) correct answers, suggesting that the information had been internalized. Cronbach alpha was calculated to be .67 for the pretest and .76 for the post-test, suggesting a moderate to high degree of internal consistency. CONCLUSIONS: Stress is a significant and regularly overlooked component of a surgeon's life. Because its effects often go unrecognized, stress frequently remains unresolved. To prevent its associated consequences such as depression, substance abuse, divorce, and suicide, educating house staff about stress is crucial. This study suggests that the symptoms, causes, and treatment of stress among surgeons can be taught effectively to surgical resident learners.

OBJECTIVE: It is unclear whether training physicians to counsel obese patients leads to weight loss. This study assessed whether a 5-h multimodal longitudinal obesity curriculum for residents on the basis of the 5As (assess, advise, agree, assist, and arrange) was associated with weight loss in their obese patients. DESIGN AND METHODS: Twenty-three primary care internal medicine residents were assigned by rotation schedule to intervention (curriculum) or control groups. We then conducted follow-up chart reviews to determine weight change at up to 12 months following the index visit. 158 obese patients (76 in the intervention group and 82 in the control group) completed exit interviews; 22 patients who presented for acute care at the index visit were excluded. Chart reviews were conducted on the 46 patients in the intervention group and 41 patients in the control group who were seen again within 12 months of the index visit and had follow-up weight measurements. RESULTS: The main outcome of interest was mean change in weight at 12 months compared between the intervention and control groups. Patients of residents in the intervention group had a mean weight loss of -1.53 kg (s.d. = 3.72) although the patients of those in the control group had a mean weight gain of 0.30 kg (s.d. = 3.60), P = 0.03. Six (15.8%) patients in the intervention group and 2 (5.4%) patients in the control group lost >5% body weight (P = 0.14). CONCLUSIONS: Although the magnitude of weight loss was small, this study shows that training physicians to counsel patients can produce measurable patient outcomes.

Deliberate practice is an important skill-training strategy in emergency medicine (EM) education. Learning curves display the relationship between practice and proficiency. Forgetting curves show the opposite, and demonstrate how skill decays over time when it is not reinforced. Using examples of published studies of deliberate practice in EM we list the properties of learning and forgetting curves and suggest how they can be combined to create experience curves: a longitudinal representation of the relationship between practice, skill acquisition, and decay over time. This framework makes explicit the need to avoid a piecemeal, episodic approach to skill practice and assessment in favor of more emphasis on what can be done to improve durability of competence over time. The authors highlight the implications for both educators and education researchers.

OBJECTIVE: To evaluate a nutrition curriculum and explore the influence of medical students' own nutrition practices on its impact. METHODS: An anonymous survey was given to first-year medical students attending a required course immediately prior to and 2 weeks after a 2-hour interactive nutrition curriculum intervention in a large private urban medical school in New York, New York. Main outcomes included self-reported nutrition counseling confidence, ability to assess diet, and nutrition knowledge measured using 4-point Likert scales. RESULTS: One hundred eleven students completed surveys pre-curriculum (69%) and 121 completed them post-curriculum (75%). The authors found overall pre-post differences in dietary assessment ability (2.65 vs 3.05, P < .001) and counseling confidence (1.86 vs 2.22, P < .001). In addition to the curricular impact, students' nutrition-related behaviors and attitudes were positively associated with outcomes. CONCLUSIONS AND IMPLICATIONS: A nutrition curriculum for medical students improves students' nutrition counseling-related confidence, knowledge, and skills even when controlling for personal nutrition-related behaviors.