Overall, the resident physicians demonstrated the least proficiency with the domaiǹ`U nderstanding the patient's perspective'' (p = 0.01, mean domain score (MDS) = 1.07). When scores were analyzed by resident year, significant maturation effects were observed for:`E xploration of problems'' (p = 0.01, MDS: R1 = 2.6, R2 = 4.2, R3 = 4.8);``Understanding the patient's perspective'' (p = 0.01, MDS: R1 = 0.28, R2 = 1.23, R3 = 1.94); and``Explaining and planning'' (p = 0.02), MDS: R1 = 1.5, R2 = 2.1, R3 = 3.4). Resident evaluations of the coaching were uniformly positive. CONCLUSION: The development of physician-patient communication skills is an essential part of resident education. The modified Calgary-Cambridge guides provide data that identifies areas of general strengths and weaknesses in communication skills. Using this instrument, we saw maturation effects in domains that require facilitation of emotional expression and shared decision-making. These results can be used to focus educational efforts, and may be useful for evaluating the impact of interventions to improve physician-patient communication. METHODS: Using a 58-item clinical teaching evaluation instrument previously employed to determine the construct validity of the framework for inpatient clinical teachers, a split sample of 4702 evaluations completed by 550 students rating 450 teachers was evaluated using factor analytic and standard item-reduction techniques. Students completed evaluations for any university-or community-based outpatient teacher with whom a minimum of three half-day teaching encounters had occurred during a one-month internal medicine ambulatory block rotation. Results were replicated using the second half of the data. Generalizability analyses were used to quantitatively determine the number of evaluations needed to obtain a stable estimate of a teacher's performance using the reduced instrument. RESULTS: As in the construct validity testing with inpatient clinical teachers, thè`k nowledge'' items statistically combined with``self-directed learning'' items and``learning climate'' items held up as a discrete construct; however, items from``control of session'',`c ommunication of goals'',``understanding and retention'',``evaluation'', and``feedback'' clustered into one remaining``global'' teaching construct. These three factors explained 67 % of the variance. Following item reduction, the three constructs were compressed to contain three items each. The items remaining in the``global'' construct were all``communication of goals'' items. Overall internal consistency of the reduced instrument was .90 with internal consistency of constructs ranging from .90-.97. The overall inter-item correlation of the reduced instrument was .55 for sample one and .54 for sample two (optimal inter-item correlations are approx =.6). A minimum of 5 evaluations are needed per teacher to obtain a generalizability coefficient > .90 using conservative estimates from both samples. CONCLUSION: For students having limited contact with outpatient teachers, setting the climate, communicating goals, and stimulating students' future learning emerge as focal areas. Further study is needed to see if this three-category framework persists as viewed by trainees with more extensive contact with outpatient preceptors. PURPOSE: Professional isolation, poor financial remuneration, and insufficient training to meet patient needs decreases career satisfaction, making rural and inner city areas less desirable for primary care practice. Changes to Internal Medicine (IM) and Family Practice (FP) residency curriculum have attempted to address health care disparities by better preparing physicians for generalist careers. The effect of these curricular changes on career satisfaction has not been examined. METHODS: We surveyed all IM (n=128) and FP (n=74) physicians 1 to 10 years after graduating from a large Mid-west community teaching hospital. The survey assessed physician and practice demographics (i.e., practice type and location, community size, case mix), career satisfaction, resource availability, and adequacy of curricular content for practice. RESULTS: Survey response was 84% (105 IM, 65 FP, p=ns). Respondents were primarily male (66%), Caucasian (88%), and in solo (13%), group (42%), or multi-specialty group practice (20%). Thirty-one percent practiced in a community of < 50,000 residents (9% < 10,000) and 28% noted some or all subspecialties were unavailable in their community. Most respondents (88.5%) were somewhat to highly satisfied with their present career, and 81% would choose medicine again as a career (78% IM, 85% FP, p=ns); those practicing in emergency room settings were least satisfied with their present career (p = 0.04). Greater career satisfaction was related to meeting expected financial remuneration (p = 0.046), satisfaction with training in palliative care (p < 0.01), faculty role modeling of compassion (p < 0.05), and support/assistance provided by residency faculty (p = 0.001). Career satisfaction was not related to community size (p = 0.6), subspecialty availability (p = 0.7), computer/internet searching skills (p = 0.11), or time spent in ambulatory training (p = 0.3). Training better focused to practice demands in differential diagnosis, neurology, orthopedics, and hematology were associated with greater career satisfaction (all p < 0.05). Using logistic regression, controlling for physician demographics, greater career satisfaction was associated with meeting financial remuneration expectations (OR=3.9, p=0.01), and better training in differential diagnosis (OR=5.8, p=0.03), and literature appraisal (OR=3.0, p=0.04). CONCLUSION: Results suggest that at this institution, nationally mandated curricular reform in several areas is associated with greater career satisfaction. Satisfaction was also related to residency faculty role modeling and support. Whether additional curricular reform further improves career satisfaction warrants investigation. The AAMC has mandated the inclusion of end-of-life (EOL) and palliative care (PC) in undergraduate medical curricula. A significant number of medical schools teach about death and dying, yet focus predominantly on ethical aspects rather than the development of clinical skills in EOL and PC. We report here on the design and implementation of an EOL curriculum directed towards specific communication skills. This curriculum was developed and initiated by students at Stanford Medical School. METHODS: A needs assessment of advanced clinical students demonstrated little formal training in EOL communication skills, while a literature review surveyed current EOL curricula on communication. These efforts were used to design a case-based curriculum that underwent faculty review. Next, faculty with national or local experience with EOL and palliative care training contributed to case development. Twelve of the faculty attended an orientation/training session on teaching the curriculum and then taught it in pairs to six groups of 10-14 medical students per group. RESULTS: The four-hour curriculum described here was taught to students at the start of their clinical training. Topics entailed breaking bad news and discussing treatment options in the setting of life-limiting illness. In two successive sections, students (1) discussed and critiqued a physician modeling these areas [Weissman DE], (2) role-played a prepared case in dyads, (3) evaluated successful elements of communication skills, and (4) assessed their performance in the role-playing dyads. CONCLUSION: Medical students require skill-based EOL and PC curricula that emphasize clinical skills specific to their level of training. This module taught early clinical students communication skills for the setting of PC and EOL care. Further interventions will be necessary to advance these students' communication skills as they progress in their clinical training. We propose next to evaluate the effectiveness of this curriculum by comparing students' EOL communication skills with standardized patients before and after this curriculum. The longitudinal clinic experience at Creighton University consists of participating in the same clinic one-half day every other week of their 2nd year of medical school in a primary care setting (general internal medicine, family practice, or pediatrics). The 4th year medical students were surveyed regarding their 2nd year longitudinal clinic experience and their 1st choice for their future career. Nonparametric correlations (phi and point-biserial coefficients) were used to assess the associations between the student's actual choice of specialty to their self-reported effect of the longitudinal clinic on their specialty choice and the specific specialty (internal medicine, family practice, or pediatrics) of the longitudinal clinic. Hometown and MCAT scores were used as control variables. RESULTS: Of the 106 students participating in the longitudinal clinic experience, 42% reported it had a positive effect on the career choice in primary care (e.g. internal medicine, family practice, or pediatrics), while 53% reported it had no effect, and the remaining 5% stated it had a negative effect. There was no association between the student's self-reported effect of the clinical experience on their actual choice of specialty (phi=.248, p=.05). There was also no association between a student's choice of specialty and whether they were involved in an internal medicine, family practice, or pediatric longitudinal clinic (p > .05 for all three comparisons). CONCLUSION: The clinic setting had no effect on the students' career choice. Other factors (e.g. market factors such as surplus/shortage of primary care physicians or clinical experiences during their 3rd year) may also be influential in such decisions. To determine if self study with a CD-ROM auscultation tool would increase internal medicine residents' knowledge and skills in cardiac auscultation. METHODS: The interactive computer-based auscultation program was developed by two of the authors. It includes 20 multi-media cases that center on common cardiovascular conditions, including valvular abnormalities, congenital heart disease, coronary artery disease and congestive heart failure. At 2 institutions, a total of 127 residents participating in their 1-month primary care rotation were enrolled in this fixed-group controlled trial from April 1999 through June 2000. Residents were assigned to the intervention or control arm based on their clinic site. Those allocated to the intervention group (n=56) were provided two hours per week during their month to use the program. Control residents (n=71) were exposed only to the content of their rotation.