COMBINING OSCES WITH THE MINI-CEX FOR RESIDENT ASSESSMENT. R.S. Crausman 1 , J.P. Miskovsky 1 ; 1 Memorial Hospital of RI, Pawtucket, RI OBJECTIVES: To assure a high standard of clinical competence throughout the continuum of medical education, it is imperative that appropriate, task-relevant evaluative tools and methods be continuously developed and applied. In response to the perceived inadequacies of conventional evaluative measures, the use of test patients for structured, standardized evaluation (Objective Structured Clinical Examination, OSCE) has gained favor for the assessment of medical students and residents. However, the role of physician faculty observer, when present, in these exercises is unclear. Physician supervisors bring a clinical perspective to the encounter different from, and complimentary to that of the standardized patient. The challenge is to provide a structured evaluative framework to improve the quality and reproducibility of assessment. In 1995 the American Board of Internal Medicine developed and validated the Mini-CEX. These observed resident-physician patient encounters consist of a single faculty member observing a resident conduct a focused history and physical examination. Residents and evaluators report satisfaction with the format, and reliability of the evaluation is thought to be superior to traditional clinical evaluation exercises. Here we describe our early experience combining the Mini-CEX with outpatient OSCE's for enhanced resident assessment. METHODS: Second year medical residents (n = 10) in our Primary Care/General Internal Medicine Residency underwent a multi-station OSCE designed to assess their clinical skills. Each 20 minute encounter was observed by a faculty physician who structured observation and assessment using the Mini-CEX instrument which uses a two page form with a 9 point rating for assessment. After each encounter both standardized patient (five minutes) and faculty physician (five minutes) provided structured feedback to the resident trainee. A time keeper assured that encounters were kept to 20 minutes. RESULTS: A structured feedback session with all participants was conducted after the exercise and all reported high levels of satisfaction with the format. Standardized patients uniformly commented that the presence of a physician faculty evaluator represented an improvement and provided complimentary evaluative information. Faculty observers were pleased with the imposed structure that the Mini-CEX provided. Residents were satisfied that feedback was appropriate and valuable CONCLUSION: In response to the perceived inadequacies of conventional evaluative measures we have introduced a combination of outpatient OSCE's and the Mini-CEX towards developing a more flexible, reliable and task-relevant teaching and evaluation tool. Our early experience with this approach has been very positive. OBJECTIVES: One of the goals of our residency program is to improve residents' ability to care for the medically underserved. We expect that our graduates will not only provide excellent clinical care to individual patients, but will also integrate public health concerns into their medical care. In addition, we anticipate that our graduates will work with community residents, organizations and leaders to serve as advocates for the underserved. In order to expose our residents to this model of community-oriented primary care, we developed an eight-week course in community medicine. METHODS: The Community Medicine seminar series was held 1/2-day each week for eight weeks and was attended by first, second and third year residents. The curriculum included a community inventory exercise in which residents obtained information about the community in which they saw continuity patients, a community assessment in which residents toured through a neighborhood on foot and described the people, businesses, housing and transportation they encountered, a community treasure hunt in which residents shopped at local businesses and map exercises in which residents plotted the location of their continuity patients' homes. A key component of the curriculum was an intranet website designed specifically for the Community Medicine course. Residents used the website to participate in on-line discussions of reading material and to access public health information and resources. RESULTS: Residents were asked to complete an on-line assessment instrument at the conclusion of the course. 91% of the residents (10/11) found the seminar series to be very useful for their future practice of medicine. 91% (10/11) felt the course should be offered again in the future. 92% (11/12) felt they understood and could explain the concept of community-oriented primary care. 73% (8/11) of the residents felt the map exercises helped them understand where their patients lived and how they traveled to medical appointments. 100% (11/11) found the public health links on the intranet website useful for learning about COPC. 73% (8/11) residents found the community treasure hunt useful in terms of how to view a community from the standpoint of its people and institutions. CONCLUSION: This Community Medicine course increased residents' knowledge of the communities in which they and their patients live. Future directions for investigation include determining whether this course impacts residents' decisions to practice primary care in underserved areas and to implement community-oriented primary care concepts after graduation from the program. OBJECTIVES: Emergency contraception (EC) is an effective but underused method of preventing unwanted pregnancy. In a 1997 national study, only 25% of college-educated women and 6% of women with high-school degrees knew key facts about EC. Only 5% of women had heard about EC from their providers. While other studies have addressed barriers to EC use in the general population, few have focused on barriers in poor, urban populations. Three residents in a program designed to train physicians to care for the underserved looked at this issue in a community satellite clinic. METHODS: As part of a Quality Improvement/Research curriculum in a primary care residency program, we conducted a focus group with eight providers at an urban, publiclyfunded community health center in San Francisco. Provider beliefs/practices, perceived patient barriers, and possible interventions to increase emergency contraception use were discussed. The session transcript was then analyzed to identify a consensus surrounding specific barriers and interventions. RESULTS: Providers identified a significant problem with unintended pregnancy at their clinic, estimated at 85 ± 90% of all pregnancies. Despite this high rate, emergency contraception was prescribed only 2 ± 3 times a year at the clinic. Providers identified the following obstacles to emergency contraception use: lack of patient knowledge regarding the availability of EC; the prevalence of social and economic stressors that made contraception a low priority for patients; patients' fatalistic beliefs surrounding pregnancy; and operational obstacles to obtaining emergency contraception prescriptions. Identified interventions to increase use/access were: patient and community education about emergency contraception; arranging to have a prepackaged product on-site to give to patients; and routine counseling by providers at all reproductive health visits. CONCLUSION: In this urban, community-based primary care clinic, unintended pregnancy is common and emergency contraception rarely used. In the focus group session, providers clarified barriers and identified interventions that the clinic could employ to increase patient's access to and use of emergency contraception. Barriers to use by urban, underserved populations may need further study and targeted interventions before true access to emergency contraception becomes a reality for this vulnerable patient group. OBJECTIVES: Increase residents knowledge of common IM approaches (acupuncture, physical therapy/massage, mind-body medicine, herbal medicine, chiropractic) including what that approach entails, what conditions it is thought to be useful for treating, and any contraindications for its use; and ability to identify, access and critically evaluate evidencedbased research regarding treatment outcomes and efficacy of the particular approach. METHODS: Residents are assigned a faculty mentor who oversees and provides guidance in the month; helps to monitor and direct the residents' learning and to address their objectives. Residents spend several 1/2 days each week in the office of IM providers. Each provider prepares a reading list the resident is responsible for working through in that area. Residents see patients along with the provider and have opportunity to discuss the patients from that IM perspective. Residents also spend time with a general internist who is well versed in IM at our Center for Integrative Medicine. They learn how primary care physicians incorporate IM into their practice. Residents attend several one-on-one classes. For example, residents meet with the librarian to learn how to search the web to find IM information and research and are introduced to IM databases in the area (i.e., Natural Medicine Database). An oncologist talks with the residents about the use of alternative techniques cancer patients often use; how the oncologist approaches discussions about IM with patients and the contraindications that may exist for various IM approaches within oncology. The residents also go on several site visits (walk through a pharmacy with the pharmacist looking at OTC herbal remedies as well as visiting a wellness center providing patient education, support groups and counseling to cancer patients. RESULTS: Intensive interviews are conducted with each resident completing the rotation to evaluate quality of the experience and to elicit opinions for changes/additions to the experience. CONCLUSION: Setting up curriculum addressing nontraditional approaches in a western medical setting raises many issues regarding developing common standards for education, reimbursement for practitioner training time and credentialing, applying research standards to cross cultural scientific literature. The process is a challenging and yet a rewarding venture for both traditional and nontraditional medical learners and educators. OBJECTIVES: A one-month IM elective block rotation was developed for third year residents to more intensively, study IM approaches. It was hoped that this exposure would prepare residents to better integrate IM into their medical practice. Increase residents knowledge of common IM approaches (acupuncture, physical therapy/ massage, mind-body medicine, herbal medicine, chiropractic)including what that approach entails, what conditions it is thought to be useful for treating, and any contraindications for its use; and ability to identify, access and critically evaluate evidenced-based research regarding treatment outcomes and efficacy of the particular approach. METHODS: Residents are assigned a faculty mentor who oversees and provides guidance in the month; helps to monitor and direct the residents' learning and to address their objectives. Residents spend several 1/2 days each week in the office of IM providers. Each provider prepares a reading list the resident is responsible for working through in that area. Residents see patients along with the provider and have opportunity to discuss the patients from that IM perspective. Residents also spend time with a general internist who is well versed in IM at our Center for Integrative Medicine. They learn how primary care physicians incorporate IM into their practice. Residents attend several one-on-one classes. For example, residents meet with the librarian to learn how to search the web to find IM information and research and are introduced to IM databases in the area (i.e., Natural Medicine Database). An oncologist talks with the residents about the use of alternative techniques cancer patients often use; how the oncologist approaches discussions about IM with patients and the contraindications that may exist for various IM approaches within oncology. The residents also go on several site visits (walk through a pharmacy with the pharmacist looking at OCT herbal remedies as well as visiting a wellness center providing patient education, support groups and counseling to cancer patients. RESULTS: Intensive interviews are conducted with each resident completing the rotation to evaluate quality of the experience and to elicit opinions for changes/additions to the experience. CONCLUSION: Setting up curriculum addressing nontraditional approaches in a western medical setting raises many issues regarding developing common standards for education, reimbursement for practitioner training time and credentialing, applying research standards to cross cultural scientific literature. The process is a challenging and yet a rewarding venture for both traditional and nontraditional medical learners and educators. OBJECTIVES: In order to effectively care for patients and promote health, physicians must have a broader view of their role in society as``health promoters''. Knowledge of public health resources as well as the process of policy development is especially important when caring for vulnerable patients. Because of the crowded curriculum of a residency program, we have developed a public health curriculum that is integrated into the existing framework of the residency program. METHODS: A needs assessment was conducted via interviews with the Primary Care interns by an outside evaluator and a survey completed by Primary Care and traditional track house officers (80% response rate). Several areas within the existing curriculum were identified where public health concepts could be inserted Ð complementing, not replacing,``traditional medicine'' topics. All sessions are evaluated. Residents will complete yearly surveys and an exit interview to assess the impact of this new curriculum. RESULTS: The resident survey showed a significant level of interest in public health, greatest in the senior residents. Residents rated their own knowledge of many public health concepts as`a verage'' to``low'', and rated a broader knowledge of public health as``important'' to``very important'' to patient care. Faculty from the Boston University School of Public Health, Boston Public Health Commission and the Massachusetts Department of Public Health have agreed to participate, and run joint sessions with faculty from the Section of General Internal Medicine. Sessions include: 1) A monthly three-hour seminar during an ambulatory block, attended by all of the residents (both Primary Care and traditional track) that reviews the history of medicine and public health, highlighting areas of tension and opportunities for collaboration. 2) Ambulatory Morning Report: topics relevant to ambulatory medicine are presented by the Primary Care chief resident and internal medicine faculty, with monthly participation by public health faculty, adding the public health perspective with a 10 ± 15 minute discussion. 3 ) A threehour session in the Primary Care seminar, focused on the role of Departments of Public Health and an introduction to health policy and government. 4) An elective rotation at the Massachusetts Department of Public Health provides primary care residents with the opportunity to work directly with public health staff, participate in projects and learn how programs and policies are developed. CONCLUSION: Our survey found that the residents were interested in public health and felt that it was relevant to clinical care. Public health faculty were very willing to participate in resident education and collaborate with curriculum development. Important public health concepts can be incorporated into a Primary Care residency curriculum without displacing existing``traditional topics''. OBJECTIVES: Since Hepatitis B (HBV), Hepatitis C (HCV) and HIV share the same high-risk behaviors, coinfection is frequent in clinical practice. In the US, 30 ± 50% of HIV patients are coinfected with chronic HCV. Almost 95% of HIV patients have serological evidence of HBV exposure. In the era of highly active antiretroviral therapy, death from rapidly progressive viral hepatitis is increasingly common in HIV patients. Since early detection and treatment of HIV and viral hepatitis has been shown to improve the outcome of patients, reactive serologies to HBV and/or HCV should provoke discussion of HIV testing in a general medicine clinic to reveal coinfection. METHODS: Retrospective chart review of patients with serological exposure for viral hepatitis, identified or followed at a hospital based general medicine clinic in East Harlem, NY. A query was done on hepatitis serologies sent from 1/1/99 to 12/31/99 from the clinic to create 3 patient groups : 1) HBV exposure (Reactive HBc only) 2) HCV exposure (Reactive HCV only) 3) Both HBV and HCV exposure (Reactive HBc and HCV). Charts were reviewed to determine whether house staff physicians documented discussions of high risk HIV behavior after obtaining the hepatitis serologies. The number of HIV tests requested and results were noted. Patient return rate for HIV results was also noted. OBJECTIVES: Most guidelines for prevention and treatment of osteoporotic fractures are neither evidence-based nor well-suited to the needs of the diverse patient population found in urban public health settings. This Quality Improvement project aimed to create a clinical guideline adapted to San Francisco's Community Health Network and its diverse population with limited resources. The Guideline aims to be based on current evidence wherever possible, and is based in part on existing evidence-based guidelines such as the National Osteoporosis Foundation (NOF) Guideline. Implementation of the guideline will follow published effective approaches to changing practice patterns. METHODS: 1. Adaptation of currently existing evidence-based guidelines, such as the NOF guideline, and review of recent relevant literature to create a guideline appropriate for and tailored to San Francisco's Community Health Network (CHN.) 2. Distribution of these guidelines to CHN providers, ideally targeting those who see our at-risk patients, using a creative media approach with paper and electronic formats (including distribution of a file transferrable to handheld organizers such as the Palm OS) and additionally promoting the guideline in a didactic format. 3. Improving awareness of and adherence to these guidelines with such techniques as Clinical Alerts on the CHN computer record, and easy Web access on the CHN website. RESULTS: We designed a guideline that was tailored to meet the needs of the CHN patient population. This guideline was evidence-based. Distribution was achieved via CHN website, computer-based reminders and triggers where appropriate, handheld organizer files, and didactic sessions in local clinics and conferences. CONCLUSION: Few guidelines for prevention and treatment of osteoporotic fractures currently exist that are both evidence-based and tailored to meet the needs of an underserved urban public health community. Using good existing guidelines such as that published by the NOF, current literature can be adapted to design a guideline that is both based on good evidence and appropriate to the limited resources of an urban public health setting. Novel uses of computer-based and didactic tools can enhance distribution and awareness of clinical practice guidelines. OBJECTIVES: To develop and implement a curriculum in women's health for internal medicine residents in a community hospital based university program. METHODS: Participants are first year internal medicine residents in their ambulatory block month (N=16). The curriculum content was determined by a needs assessment conducted on previous and current residents. It consists of the following six units covered during three hourly didactic sessions: 1) Pretest and Introduction to Women's Health, 2) Selected Gynecological Conditions, 3) Obesity and Eating Disorders, 4) Menopause, Osteoporosis and Hormone Replacement, 5) Psychosocial Issues, 6) Resident Presentations and Posttest. Also included in the curriculum is a three-hour visit to the local domestic violence prevention center. All necessary reading materials are handed out during the first session after the pretest. The didactic sessions start with a brief case presentation by the participating resident(s); this is followed by an in-depth discussion of the topics of the day with expected resident participation. Each session except the introductory and resident presentation session ends with role-plays where the instructor plays the role of the patient and the resident the doctor. This enables the resident(s) to put into immediate practice what they have just learned. Clinical practice of women's health is expected to occur when residents see female patients in their primary care practices. To expand the scope of this curriculum beyond these limited topics both residents and faculty have been encouraged to incorporate into everyday teaching and learning how various conditions may differ or are unique in women. Participating residents are expected to make a formal thirty to forty-five minute presentation on a topic in women's health not covered in this curriculum. Learners are evaluated by the completion of a standard evaluation form used in the residency program. Evaluations are based on the residents' performance on the posttest, participation during the didactic sessions and their presentations. Learners evaluate the curriculum by completing a survey. RESULTS: The curriculum was well received by all residents. All residents surveyed either agreed or strongly agreed that they would now be able to evaluate, manage or appropriately refer female patients as a result of knowledge gained during the month. The mean posttest score was 81%, an improvement over the mean pretest score of 66%. Residents stated particularly that role-plays helped improve their understanding of the topics. A survey of these residents in their third year regarding their perceptions on the women's health education they received in this program and how well they think it has prepared them for their future practices year is planned. CONCLUSION: The curriculum improved the knowledge of residents in selected women's health topics. Using the same curricular model, topics can be adapted to meet the learning needs of residents in other residency programs.