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PURPOSE: To assess the skills of internal medicine-pediatrics (med-peds) residents in evaluating and counseling patients with complex psychosocial problems using a clinical performance exercise (CPE). METHOD: The authors designed a 13-station CPE [nine standardized-patient (SP) stations and four non-SP stations]. Eight of the SP stations focused on counseling or assessing complex psychosocial needs, and three were videotaped and analyzed for specific verbal and nonverbal communication skills. Residents completed a written task for each station and SPs completed a checklist on interviewing and communication skills and a 52-item patient's-satisfaction survey. All first- and third-year residents (n = 25) from two academic years participated. RESULTS: The range of the average scores on the nine SP stations was 43-75%. The residents performed better with common problems (newborn hospital discharge instructions and cardiac risk-factor counseling) than with more complex problems that are less often encountered in the institution (HIV counseling), or problems less often recognized (adult survivor of childhood sexual abuse). As expected, third-year residents scored better than did first-year residents on the written "plan" part of the SP stations and on the non-SP stations. Third-year and first-year residents had similar scores, however, on measures of verbal and nonverbal communication and patient's satisfaction, and for gathering data and providing information. CONCLUSION: This is the first performance-based evaluation of residents in a combined med-peds residency program. The stations addressed more complex clinical skills than those reported for objective structured clinical evaluations of residents.

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BACKGROUND: The assessment of performance in the real world of medical practice is now widely accepted as the goal of assessment at the postgraduate level. This is largely a validity issue, as it is recognised that tests of knowledge and in clinical simulations cannot on their own really measure how medical practitioners function in the broader health care system. However, the development of standards for performance-based assessment is not as well understood as in competency assessment, where simulations can more readily reflect narrower issues of knowledge and skills. This paper proposes a theoretical framework for the development of standards that reflect the more complex world in which experienced medical practitioners work. METHODS: The paper reflects the combined experiences of a group of education researchers and the results of literature searches that included identifying current health system data sources that might contribute information to the measurement of standards. CONCLUSION: Standards that reflect the complexity of medical practice may best be developed through an "expert systems" analysis of clinical conditions for which desired health care outcomes reflect the contribution of several health professionals within a complex, three-dimensional, contextual model. Examples of the model are provided, but further work is needed to test validity and measurability.

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CONTEXT AND OBJECTIVES: Good clinical teaching is central to medical education but there is concern about maintaining this in contemporary, pressured health care environments. This paper aims to demonstrate that good clinical practice is at the heart of good clinical teaching. METHODS: Seven roles are used as a framework for analysing good clinical teaching. The roles are medical expert, communicator, collaborator, manager, advocate, scholar and professional. RESULTS: The analysis of clinical teaching and clinical practice demonstrates that they are closely linked. As experts, clinical teachers are involved in research, information retrieval and sharing of knowledge or teaching. Good communication with trainees, patients and colleagues defines teaching excellence. Clinicians can 'teach' collaboration by acting as role models and by encouraging learners to understand the responsibilities of other health professionals. As managers, clinicians can apply their skills to the effective management of learning resources. Similarly skills as advocates at the individual, community and population level can be passed on in educational encounters. The clinicians' responsibilities as scholars are most readily applied to teaching activities. Clinicians have clear roles in taking scholarly approaches to their practice and demonstrating them to others. CONCLUSION: Good clinical teaching is concerned with providing role models for good practice, making good practice visible and explaining it to trainees. This is the very basis of clinicians as professionals, the seventh role, and should be the foundation for the further development of clinicians as excellent clinical teachers.

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PURPOSE: This article discusses the importance of the process of evaluation of clinical teaching for the individual teacher and for the programme. Measurement principles, including validity, reliability, efficiency and feasibility, and methods to evaluate clinical teaching are reviewed. CONTEXT: Evaluation is usually carried out from the perspective of the learner. This article broadens the evaluation to include the perspectives of the teacher, the patient and the institutional administrators and payers in the health care system and recommends evaluation strategies. RESULTS: Each perspective provides specific feedback on factors or attributes of the clinical teacher's performance in the domains of medical expert, professional, scholar, communicator, collaborator, patient advocate and manager. Teachers should be evaluated in all domains relevant to their teaching objectives; these include knowledge, clinical competence, teaching effectiveness and professional attributes. CONCLUSIONS AND IMPLICATIONS: Using this model of evaluation, a connection can be made between teaching and learning about all the expected roles of a physician. This can form the basis for systematic investigation into the relationship between the quality of teaching and the desired outcomes, the improvement of student learning and the achievement of better health care practice. It is suggested that the extent of effort and resources devoted to evaluation should be commensurate with the value assigned to the evaluation process and its outcomes.

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BACKGROUND: The Council on Graduate Medical Education's (COGME) Fifth Report on Women and Medicine states that "changes in undergraduate and graduate medical education, in addition to continuing medical education, are needed to address adequately the comprehensive health needs of women." Primary care physicians (PCPs) who completed residency training prior to the establishment of new guidelines for women's health education are dependent on continuing medical education (CME) to update their knowledge and skills. METHODS: Primary care physicians attending a university-based CME program in family medicine were surveyed (n = 300) about their need for CME in women's health topics. Responses were analyzed using chi-square analysis and Pearson correlations. Topics of interest were compared with women's health competencies published in 1997 by the American Board of Internal Medicine (ABIM) and in 1997 by the American Academy of Family Physicians (AAFP). RESULTS: Of 30 women's health topics listed, 22 were of interest to 50% or more of respondents and 11 were of very high interest (p < .05). Respondents most interested in women's health CME were most likely to believe CME would reduce the number of referrals currently required to evaluate women's breast problems. Topics of interest also align well with ABIM and AAFP competencies in women's health. CME in comprehensive women's health care is therefore of high interest to our respondents and topics of greatest interest are identified. IMPLICATIONS: Areas of interest correlate well with new requirements by ABIM and AAFP and should be targeted by CME programs.

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PURPOSE: To evaluate the impact of an interdisciplinary medicine-surgery clerkship (created to foster generalist education) on students' performances on National Board of Medical Examiners' (NBME) subject examinations. METHOD: Test data for the 226 students who participated in the 16-week combined clerkship and for the 265 students who had completed the traditional clerkships (12 weeks of medicine, 12 weeks of surgery) were compiled and analyzed using t-tests for independent samples. RESULTS: Mean scores on the NBME subject examination in medicine increased significantly after the combined medicine-surgery clerkship (from 433 to 455, p < or = 0.5). Mean scores on the NBME subject examination in surgery were similar to those achieved in the traditional clerkship years. CONCLUSION: Since the medicine and surgery clerkships were combined into a single, interdisciplinary clerkship, students' scores have increased on the medicine NBME subject examination and have remained relatively unchanged on the surgery NBME subject examination, despite a substantial reduction in students' clinical experience in the combined clerkship from the traditional clerkships (16 vs 24 weeks).

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PURPOSE: To see whether fourth-year medical students can teach the physical examination to first-year students as effectively as can faculty preceptors. METHOD: Ninety-three first-year students studying the physical examination were randomly assigned to one of ten fourth-year student preceptors or one of 15 faculty preceptors. Test results and course evaluations were compared by type of preceptor. Fourth-year student preceptors were surveyed regarding their experience. RESULTS: The mean test scores did not differ between the first-year students with fourth-year student preceptors and those with faculty preceptors. The first-year students rated the fourth-year student preceptors higher than they did the faculty preceptors. The fourth-year students rated their experience favorably. CONCLUSION: A select group of fourth-year medical students provides a successful alternative to faculty in the teaching of the physical examination to first-year students.

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OBJECTIVE: To determine if fourth-year medical students are as effective as faculty in teaching the physical examination to first-year medical students. DESIGN: Stratified randomization of the first-year students. SETTING: A public medical school. PARTICIPANTS: All 100 first-year medical students in one medical school class were randomly assigned (controlling for gender) to either a faculty or a fourth-year student preceptor for the Physical Examination Module. MAIN RESULTS: The first-year students of faculty preceptors scored no differently on the written examination than the students of the fourth-year medical student preceptors (82.8% vs 80.3%, p = .09) and no differently on a standardized patient practical examination (95.5% vs 95.4%, p = .92). Also, the first-year students rated the two groups of preceptors similarly on an evaluation form, with faculty rated higher on six items and the student preceptors rated higher on six items (all p > .10). The fourth-year student preceptors rated the experience favorably. CONCLUSIONS: Fourth-year medical students were as successful as faculty in teaching first-year medical students the physical examination as measured by first-year student's performances on objective measures and ratings of teaching effectiveness.

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It was hypothesized that internal medicine housestaff who inquire into their hospital patients' social histories would be rated by nurses and attendings as having better interpersonal skills. Thirty-seven internal medicine housestaff were asked to answer a questionnaire regarding the social history of up to three of their hospital patients. The score on these questionnaires was then compared to evaluations by nurses and attendings of housestaffs' interpersonal skills. We found that nurses' evaluations of housestaff interpersonal skills correlated with performance on the social history questionnaire, while attendings' evaluations did not. Social history inquiry by housestaff may be a marker for housestaff humanistic and interpersonal skills.

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