T. Houston 1 , R. Connors 1 , N. Cutler 1 , M. Nidiry 1 ; 1 Johns Hopkins University, Baltimore, Maryland STATEMENT OF PROBLEM OR QUESTION: Although a highly rated Rheumatology rotation exists, our residents rated their training in``primary care'' musculoskeletal medicine (knee pain, biceps tendonitis, epicondylitis, ankle sprain, injections, etc.) as less than optimal. OBJECTIVES OF PROGRAM/INTERVENTION: Success in``Primary Care'' Musculoskeletal Medicine training was limited by lacking primary care preceptors trained in musculoskeletal problems and by not having a concentrated collection of patients with musculoskeletal problems. Our OBJECTIVE was to establish an innovative primary care musculoskeletal medicine clinic precepted by general internists with additional training in joint issues. DESCRIPTION OF PROGRAM/INTERVENTION: In the planning year, faculty attended special musculoskeletal training sessions sponsored by SGIM and Rheumatology organizations, attended orthopedic clinics, and assembled a musculoskeletal patient population. Triage nurses were instructed to only schedule patients with acute and chronic joint problems to a special clinic session at a community-based practice site. One half-day per week, residents interviewed patients, discussed diagnosis and management with faculty, and then were supervised during procedures. The curriculum also included group discussions focusing on diagnosis and treatment (medications, physical therapy, etc) of musculoskeletal problems not covered in the Rheumatology rotation, skills practice with injection models, and a reference syllabus. FINDINGS TO DATE: Our evaluation of the musculoskeletal clinic within the first six months focused on the success in achieving a concentrated experience for the first six residents to participate in the rotation. Residents averaged seeing 4.3 patients with musculoskeletal complaints per half-day clinic. The most common musculoskeletal complaints were knee pain(25%), back pain(19%), shoulder pain(16%), and hip pain(9%). In treating these patients, residents performed a mean of 2.0 procedures per half-day clinic. The most common procedures included injections of the : knee, subacromial region, and trochanteric bursa. Residents have uniformly rated the usefulness of the clinic as very good/superb. An additional pre-post knowledge and skills assessment of residents will be completed at the end of the two-year curriculum. KEY LESSONS LEARNED: Our needs assessment indicated that residents wanted additional training in musculoskeletal medicine, but preferred to learn in a primary care setting. Despite the logistic challenges, our curriculum has demonstrated the feasibility of a concentrated primary care musculoskeletal medicine experience. STATEMENT OF PROBLEM OR QUESTION: Medical advice and nicotine replacement are effective smoking cessation interventions. However physicians have a limited impact as they miss many opportunities to help smokers quit and often lack the necessary counseling skills. As smoking cessation is a stepwise process, physicians should tailor counseling to each smoker's motivation to quit. OBJECTIVES OF PROGRAM/INTERVENTION: We designed a program based on active learning methods and the``stages of change model'' to train physicians in smoking cessation. At the end of training, physicians should be able to: (1) assess each smoker's motivation to quit; (2) advise all smokers with strategies matching their motivation to quit; (3) prescribe pharmacotherapy to smokers ready to stop. DESCRIPTION OF PROGRAM/INTERVENTION: In two 4-hours sessions, active educational methods enable participants to progressively learn these new skills. In the first session, learners use a checklist to observe 3 videotaped encounters with smokers and identify the 3 main stages of motivation to quit. An interactive workshop follows for presentation and discussion of basic concepts and strategies of smoking cessation in relation to videotaped cases. Then participants are involved alternatively as physician, patient and observer in role plays with smokers at various motivation stages. In the second session, learners practice counseling skills with trained standardized patients who portray smokers with different profiles and readiness to quit. Trainees also receive a reference document, pocket algorithms, a record sheet for smokers, 5 stage-matched brochures for patients and instructions to patients about use of nicotine replacement. FINDINGS TO DATE: We tested this training program in a randomized trial among residents in primary care clinics. Compared to the control group, trained residents provided smoking cessation interventions of higher quality (mean score: 4.0 vs. 2.7, p=0.01, range: 0 ± 14) and expressed higher confidence in their skills 3 months after training (mean score: 7.7 vs. 5.2, p=0.002, range: 0 ± 10). Moreover, 1-year smoking abstinence almost doubled among smokers visiting trained residents (13% vs. 7%, p=0.04). KEY LESSONS LEARNED: We could develop a physician training program in smoking cessation based on active and progressive learning of counseling skills. This program was effective to improve physicians' practices and smokers' cessation rate. If this training is implemented at a large scale, physicians could contribute more effectively to reduce smoking prevalence and its major health consequences. ; 2) To allow interested PGY-2 and -3 residents an opportunity to work closely with faculty in developing publicspeaking, advocacy, and teaching skills. DESCRIPTION OF PROGRAM/INTERVENTION: Two PGY-2 residents were identified who had an interest in DV. These residents helped to design a 3-hour curriculum which was implemented on a monthly basis for all interns during their Ambulatory Medicine rotation. The curriculum consisted of: 1) A portion of a video about DV survivors; 2) A lecture on the dynamics, screening, and management of DV; 3) A handout including articles on DV and an annotated bibliography; 4) A talk by a social worker on principles of counseling and local resources for survivors of DV; 5) A role play demonstrating screening strategies; 6) An interactive discussion of three cases of``positive``results of screening; 7) Small group sessions in which the interns were given case scenarios and asked to try the screening and management techniques they had learned. The lecture was given by the lead author, who is a faculty member. Elements 5 ± 7 of the curriculum involved the PGY-2 residents to an increasing degree over the course of the spring. FINDINGS TO DATE: The curriculum was well-received by the interns. Both the lecture and the portions led by the PGY-2's were consistently rated highly in feedback obtained at the conclusion of the sessions. The interns commented frequently on the benefits of the role playing. We were also able to identify several interns interested in DV who have been recruited to participate in the curriculum this spring. KEY LESSONS LEARNED: Residents respond well to learning skills of outpatient medicine from their peers, whom they may feel have a better sense of the limitations and realities of their own practice. Many housestaff have an interest in both the care of vulnerable patients and advocacy that is rarely put to use in the traditional IM residency. Curriculum design and implementation can be made easier and more appealing by involving residents with specific interests. Faculty can serve as mentors in order to facilitate resident academic growth and development. The educational intervention consisted of a 3-hour interactive seminar on DV, including discussion of video material, case discussion, an evidence-based literature review, and role-playing. The seminar was designed to heighten awareness of abuse as a problem in the primary care setting, and to teach the importance of screening and useful techniques for screening. After the seminar, residents were asked to screen all of their female patients for DV for the next 2 weeks, and return to discuss their findings in a follow up seminar. Six to 12 months after completing the intervention, all second and third year residents received a questionnaire containing eight modified essay questions concerning clinical scenarios. All PGY3 residents surveyed (intervention group) had received the educational intervention while none of the PGY2 residents (control group) had received it. The residents were unaware of the purpose of the questionnaire, and all responses were anonymous. Three of the eight cases described scenarios in primary care which were designed to stimulate a suspicion of DV, for which residents were asked to list up to five leading diagnoses. A response was counted as correct if it contained the words``violence'' or``abuse.'' Questionnaires with at least 2 correct responses (to the 3 suspicious questions) were graded as positive for demonstrating adequate suspicion of DV. FINDINGS TO DATE: The program was well-received, with an average rating of 4.6 on a 5point scale (n=33.) As of 12/29/00, response rates were 70% (26 of 37) in the intervention group and 51% (19 of 37) in the control group. The rates of "positive questionnaires" were 21% (4/19) for the control group and 58% (15/26) for the intervention group (p=.014) KEY LESSONS LEARNED: An educational intervention in domestic violence using video, case discussion, evidence-based review and role-playing was well-received, changed physician awareness of domestic violence in primary care, and had a lasting effect six to 12 months after the intervention. DESCRIPTION OF PROGRAM/INTERVENTION: We will demonstrate the session plans of two EBM courses. Course 1 consists of an introduction session in which staff present the fundamentals of asking clinical questions, searching for the best evidence, and critiquing articles. Afterwards, one resident prepares a patient case and presents it to the group. The resident then formulates a clinical question and searches for the best evidence to answer it. The resident must individually meet with a staff preceptor to review the answer. Each week a different resident presents a case, formulates the question, meets with a staff preceptor, and presents the findings to the group. EBM Course 2 consists of five didactic sessions. The first session is the same as for Course 1. The subsequent sessions include staff presenting methods on how to evaluate articles of diagnosis, therapy and prognosis. The students and staff then discuss cases, formulate clinical questions and go to the library together to search for answers. The group reconvenes to critique the search strategies. FINDINGS TO DATE: Residents (N=12) in both courses completed the same 32-item questionnaire on the first and last sessions. Residents were asked the amount of searching done, comfort in searching/critiquing findings, applying findings to patient care, and what data source they'd search first to answer a particular clinical question. Pre and post differences were tested with the Wilcoxon Signed Ranks test. Comments from Course 1 regarding the need for more time to learn how to search prompted formal didactic sessions for Course 2. Course 2 residents significantly increased their frequency of searching for answers to clinical questions/applying EBM(Z = 2.02, p = .028). They reported more confidence in their ability to conduct quality searches (Z = 2.21, p = .027) and to critique the articles(Z = 2.23, p = .026). Residents from both courses mentioned that they learned about many new sources of medical information on the Internet and library databases. KEY LESSONS LEARNED: These courses may be effective means to increase residents' confidence to conduct EBM searches and to evaluate results. These courses are important ways to recruit staff to actively further their own education and application of EBM. Subsequently, they spent an afternoon session in groups of four students, one faculty coach and four standardized patients (SP's). Each student interviewed a patient, received verbal and written feedback from his/her peers, from the coach, and from the SP. Then they would re-do parts of the interview based on suggestions. At the end of the year, students interviewed a different SP case for a final exam, and were rated by instructors, the SP and themselves. The videotapes of these evaluations are then reviewed one on one with a faculty member trained in this process. FINDINGS TO DATE: In contrast to group lectures and small group sessions, students were most highly engaged in the group practice sessions with the SP's. Many students used a high control interview, but with feedback, rapidly learned to use more patient-centered interview techniques. KEY LESSONS LEARNED: After trying several didactic methods (lecture, small group workshop of 10 ± 15 students, optional videotape review sessions), we found that students responded best to a carefully facilitated SP session within a very small group (4 students) with immediate feedback from student colleagues, coach and SP. STATEMENT OF PROBLEM OR QUESTION: The first 2 years of medical school are filled with a seemingly endless stream of new information. While the basic science classes are similar to prior learning experiences, clinical learning, which may be more satisfying (i.e.,``feeling like a doctor''), requires skills that are relatively new and different. History taking skills are often evaluated by Observed Structured Clinical Exams (OSCE) or by direct observation and feedback. The traditional method of understanding the medical history is often a static list of questions and categories that fail to direct the flow of the student-patient interaction. In addition, students often desire more feedback than is possible to provide in a busy office setting. OBJECTIVES OF PROGRAM/INTERVENTION: This project seeks to create and implement a system by which medical students can understand, self-evaluate, and improve their history taking skills. DESCRIPTION OF PROGRAM/INTERVENTION: The subjects were 8 first-year medical students at Dartmouth Medical School enrolled in the On Doctoring course ± a longitudinal clinical care experience for all students in years 1 and 2. The students alternate one half-day per week with a facilitator in a small group setting, then one half-day one-on-one with a preceptor in an ambulatory setting. In the small group, the facilitator (GSO) and the students together built a process flow diagram of the medical history placing a strong emphasis on the transitions of the process. This process diagram was then used as a template for students to evaluate and improve their history taking skills.``History scorecards'' were given to the students for use in their subsequent preceptor visits. At the preceptor's office, immediately after taking a history, the student rates several aspects of the interaction (e.g., introduction of self, agenda setting, use of silence) on a 10-point scale for each patient encounter. FINDINGS TO DATE: On the subsequent preceptor visits, 25% of students used the``history scorecards'' to evaluate their performance. Those who used the system found it easier to track their skills and to ask for directed feedback from their preceptor. Those who did not use the system either forgot to bring the scorecard, found it cumbersome, or did not realize that it was an``assignment.'' KEY LESSONS LEARNED: In addition to learning history taking skills, students design a process diagram, analyze the process to find aspects that can be changed/improved, and collect and analyze data so as to monitor improvement. This novel way of teaching and learning the medical history incorporates elements of evidence based decision making for directed feedback and quality improvement skills that are important for students to understand. Graduate Medical Education, and the results of needs assessments of internal medicine residents at our institution. Using Medline, an extensive literature search was performed on the following topics: osteoporosis, breast cancer, hormone replacement therapy, domestic violence, coronary artery disease in women, menopause, headaches, substance abuse in women, urinary incontinence, dementia, sexual dysfunction, and evidence-based medicine to create a bibliography of readings for residents who rotate through our women's health center. Peerreviewed journal articles were compiled. Priority was given to data published since 1990, and randomized, double-blinded, placebo controlled studies. Faculty and residents review and analyze two to four articles weekly on a given subject. Content experts provide context and clinical expertise to discussions. Clinical questions, such as``What is the risk of my patient developing breast cancer on hormone replacement therapy?''; and``Should I prescribe hormone replacement therapy to my post-menopausal patient to help prevent coronary artery disease?'' are addressed in each session. Evidence-based medicine core concepts are reviewed and applied, including the number needed to treat, absolute risk reduction, and relative risk. FINDINGS TO DATE: Previous work from a needs assessment of residents at our institution found a discrepancy in perceptions and actual knowledge in women's health. Ninety-one percent of the residents rated inadequacies in the women's health curriculum. Our evidencedbased curriculum serves to bridge this gap of knowledge. Residents participating in our curriculum have expressed increased knowledge in the subjects discussed in our weekly conferences. Also, residents have stated that much of what is taught in this curriculum has not been covered elsewhere in their residency curriculum. KEY LESSONS LEARNED: A gap exists to be filled between perceptions of curriculum adequacies in women's health and actual knowledge. Our curriculum serves as a forum for an update in women's health literature, an exchange of ideas for the improvement of women's health as it is taught in internal medicine, and for further elucidation of the evidence behind what we practice and teach. ; 2) individualized educational tutorials using the assessment videotapes and published guidelines; and 3) measurement and feedback of practice patterns relative to standards of care. The efficacy of this model was assessed through a randomized trial of educational interventions for two independent guidelines. After initial assessments with standardized patients, 28 internal medicine residents were randomly assigned to receive either the guideline intervention for elders at risk for depression or the guideline intervention for patients with diabetes. All residents in the study are reassessed through direct observation with standardized patients and through chart review of a panel of clinic patients, thus providing independent comparative measures of competence. The two randomized groups are being compared on a measure of the difference in performance with diabetic patients and elderly patients. This study design, using two interventions, has the potential to double the effect size producing a more powerful study than one with a single intervention for research involving small numbers of residents. FINDINGS TO DATE: To date, half of the residents in the intervention have been reassessed using standardized patients. These results show that residents with the diabetic intervention performed better with their diabetic patients than with their elder patients, and the reverse was found for the residents trained in elder care. Difference between the diabetes trained (n=7) and elder care trained (n=6) residents on their difference in performance on two diabetes cases versus two elder care cases was large. The effect size of the two interventions (combined) was .72 standard deviation units (+/-.27 standard errors) and significant (p = .02). These results were consistent for the component score differences for history taking, physical examination, and diagnosis, but inconsistent for management plan. KEY LESSONS LEARNED: The overall advantage of the intervention is an educational experience that involves faculty and residents in an interactive learning and evaluation setting. Added benefits are the development of new tools to measure quality and physician compliance with guidelines for patient care. Videotape review of standardized cases, tutorial outlines and chart review templates used in the study will be available at the exhibit. sheet``to model searching behavior that will assist the learner in executing effective searches for clinical decision-making activities for the case studies. To conclude the topic, the nursing informatics educator/webmaster identifies quality patient education resources for the specific outpatient topics. An online submission form sends case study answers via e-mail to the clinical faculty or chief resident for evaluation prior to the outpatient conference. The case study submission is also filed on the website server for future reference. FINDINGS TO DATE: This approach has a strengthened the preparatory behavior of Internal Medicine residents in relation to the outpatient curriculum. Year 1 of a 3-year follow-up prepost resident self-report suggests mosest changes in attitudes and EBM behaviors (p < .10). The lead resident submits information prior to the group presentation. The monitor receives the residents' answers via e-mail and addresses significant issues confidentially. KEY LESSONS LEARNED: The outpatient website has increased the use of EBM clinical decision-making tools in the clinical practice settings. It has provided opportunities for improving residents' information literacy skills and knowledge of quality patient education resources. Attending physicians and monitors are requesting additional education related to information literacy and evidence-based medicine. Clinical activities take place in 3 ambulatory settings: a primary care clinic serving mainly people of lower socio-economic status and migrants, a geriatric clinic delivering home care to fragile elderly patients, a unit caring for patients with alcohol or illicit drug abuse. Students attend 8 tutorials for clinical reasoning and problem solving regarding common ambulatory conditions. A workshop based on role plays sensitizes students to counseling for smoking cessation or alcohol use. All students must also present and comment a clinical case to their colleagues. Time is allocated for self-directed learning to prepare some activities. Students receive formative assessment based on their behavior in clinical activities and their ability to solve a new clinical problem. FINDINGS TO DATE: At the end of the clerkship, students evaluate its various aspects on a 5point scale. After the first year, 108 students expressed a high global satisfaction with the clerkship (mean score: 4.2). Mean scores were also high for key elements like achievement of learning objectives (4.3), organization (4.5) and quality of teachers (4.6). KEY LESSONS LEARNED: We successfully developed a structured clinical clerkship in community medicine enabling students to learn about ambulatory care and health of vulnerable populations. This program met students' expectations and was highly appreciated. Further research should assess the impact of this clerkship on clinical competences in ambulatory care and career choices at the end of undergraduate training. Medicine residents lack self-confidence and competence in end-of-life patient care, including breaking bad news, patient goal-setting, DNR discussions and death pronouncement. In 1999, we formed a working group to teach and evaluate these core communication skills in our Internal Medicine residency program.