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Personal digital assistant for “real time” assessment of women's health in the clinical years
Personal digital assistant for “real time” assessment of women’s health in the clinical years Amy M. Autry, MD, Deborah E. Simpson, PhD, Dawn St. A. Bragg, PhD, Linda N. Meurer, MD, Vanessa M. Barnabei, MD, PhD, Sandra S. Green, MD, Chad Bertling, MS, and Barbra Fisher, MD, PhD Milwaukee, Wis OBJECTIVE: To assess in “real time” the degree to which women’s health competencies are addressed in the clinical curriculum by using a personal digital assistant. STUDY DESIGN: Competencies for women’s health were developed. Twelve students were supplied with a personal digital assistant, pre-loaded with a patient log system, for use in assessment of the inclusion of these competencies in the clinical arena. The students received instruction on completing the log for each patient for whom they were primarily responsible. RESULTS: There were 2690 total encounters. In clerkships other than obstetrics and gynecology, gender was discussed in 10% to 20% of encounters. Other than obstetrics and gynecology diagnostic categories, no more than 15% of diagnoses included gender discussion. CONCLUSION: Student recording of patient encounters reveals a minimal amount of women’s health discussion in the clinical years; however, the personal digital assistant is an effective tool with which to monitor curriculum content in the clinical setting. (Am J Obstet Gynecol 2002;187:S19-21.)
Key words: Personal digital assistant, women’s health
Recognizing the need to better incorporate women’s health into our curriculum, the Curriculum and Evaluation Committee (CEC) of the Medical College of Wisconsin established an ad hoc committee to perform a needs assessment. The committee established a set of comprehensive longitudinal competencies that were approved by the CEC. A multi-methods needs assessment was performed to establish the presence of women’s health in the medical school curriculum. Results of the needs assessment revealed crucial gaps in our curriculum with regard to women’s health. Fourth-year students, in focus groups conducted as part of the needs assessment methodology, stated that the majority of their education in women’s health occurred during their clinical years. Because retrospective reports are subject to bias and provide limited insight into actual clinical teaching provided to students during their clerkships, this study was designed to utilize personal digital assistants (PDAs) to obtain a “real time” assessment of women’s health teaching during third-year clerkships.
From the Medical College of Wisconsin, Milwaukee. Supported by Medical College of Wisconsin Learning Resource Grant. Presented as a poster at Central Group on Educational Affairs–Association of American Medical Colleges, Minneapolis Minn, March 15-18, 2001. Reprints are not available from authors. © 2002, Mosby, Inc. All rights reserved. 0002-9378/2002/$35.00 + 0 6/0/127367 doi:10.1067/mob.2002.127367
Material and methods An ad hoc committee of the medical school’s CEC was established to assess the degree to which core competencies in women’s health were addressed in our medical student curriculum. A hand-held computer system was developed to assess the inclusion of the CEC-approved set of women’s health objectives during clinical components (eg, attending rounds, case presentations) of the required third-year medical student rotations. Twelve students (6 women and 6 men) were selected to participate on the basis of their third-year track schedule and prior involvement in medical school–related organizations (CEC, Admissions Committee, Student Assembly). These students were supplied with a PDA, which was pre-loaded with point-of-case software (Five Minute Clinical Consult, Lippincott, Williams and Wilkins, Philadelphia, Pa) and a brief patient log system created by using PenDragon forms (Pendragon Software Corporation, Liberty, IL). One student piloted the system before an orientation session to verify ease of utility and appropriateness of questions. During the 1-hour orientation, students received instruction on how to complete the log for each patient for whom they were primarily responsible. The log included rotation, clinical setting (eg, ambulatory, inpatient), gender of teacher and patient, patient’s diagnosis, and whether gender’s impact on disease was discussed. The students downloaded their logs to a central computer every 2 weeks. Each student signed an informed consent form before participation in the project. S19
S20 Autry et al
Fig 1. Gender discussion by diagnostic category. C-V, Cardiovascular; GI, gastrointestinal; ID, infectious diseases.
Fig 2. Gender discussion by clerkship. Dots, Total encounters. Diamonds, Encounters where gender was discussed.
A senior analyst in the education department extracted 8 months of downloaded data (November 2000-June 2001). Diagnosis, clerkship, whether gender was discussed, and variables including teacher gender and hospital setting were cross-tabulated and analyzed for significance. Chi-square and Fisher exact tests were used as appropriate. Results Students recorded a total of 2690 patient encounters with no major technical difficulties resulting in student dropout or loss of data. The highest diagnostic categories
September 2002 Am J Obstet Gynecol
Fig 3. Diagnostic categories with gender discussion by clerkship. C-V, Cardiovascular.
documented were as follows: obstetrics and gynecology, 638 (23%); cardiovascular, 360 (13%); psychiatry, 331 (12%); gastrointestinal, 310 (12%); pulmonary, 104 (4%); dermatology, 103 (4%); infectious disease, 89 (3%); and neurology, 88 (3%). The top 5 diagnostic categories in which gender was discussed were obstetrics and gynecology, psychiatry, cardiovascular, neurology, and pulmonary. Fig 1 shows the relationship of number of patient encounters in diagnostic categories to number of these encounters in which gender was discussed. Except for obstetrics and gynecology, approximately half of all patients in the top 5 diagnostic categories in which gender was discussed were female. Obstetrics and gynecology, psychiatry, and neurology had sufficient “gender-discussed” encounters to perform further analysis. Forty-six percent of obstetrics and gynecology encounters included gender discussion. Gender discussion was significantly more likely to occur in the inpatient setting (P = .007). Twelve percent of psychiatry encounters included gender discussion, which was much more likely to occur when the patient was female (P = .047) but was unaffected by hospital setting. Five percent of patients with a neurologic diagnosis had gender discussed with no difference by patient gender or hospital setting. There was no significant effect of teacher gender on probability that gender would be discussed in obstetrics and gynecology–, psychiatry-, or neurology-related diagnostic categories. Gender discussion by clerkship was variable (see Fig 2). Cross-tabulation of gender discussion by clerkship revealed that 51% of these encounters occurred in obstetrics and gynecology, 15% in pediatrics, 12% in psychiatry and medicine, 5% in family medicine, 2.5% in surgery, and 1.6% in anesthesia.
Autry et al S21
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Fig 3 shows diagnostic categories in which gender discussion occurred by clerkship. For example, 90% of gender discussion in the obstetrics and gynecology diagnostic categories occurred during the obstetrics and gynecology clerkship, 6% during the anesthesia clerkship, and 3% during the medicine clerkship. Among the cardiovascular disease categories, 55% of gender discussion occurred during the medicine clerkship, 25% during the family medicine clerkship, and 11% during the surgery clerkship. On the other hand, during the obstetrics and gynecology clerkship, 12% of gastroenterology encounters, 64% of infectious disease encounters, 85% of oncology encounters, and 14% of preventive medicine encounters included a discussion of gender. Comment In 1998, new guidelines from the Liaison Committee on Graduate Medical Education mandated that clinical experiences be equivalent across sites within the same clerkship and that mechanisms for tracking and validation of clinical clerkship goals and objectives be established at the individual student level.1 Results from the 2000 Senior Graduation Questionnaire from the Association of American Medical Colleges reveal that 25% of students report inadequate instruction in women’s health.2 There have been multiple reports of the successful use of computerized or handheld computer log systems for documentation of student experience.3 This study represents our attempt to use a PDA to assess “real time” clinical experiences in the area of women’s health and ultimately monitor curriculum reform. Our results were disappointing yet revealing from a gender health perspective. Other than obstetrics and gynecology, no diagnostic category included a discussion of gender’s effect on health or disease more than 15% of the time. In clerkships other than obstetrics and gynecology, gender was discussed in only 10% to 20% of patient encounters. One must evaluate obstetrics and gynecology clerkship experiences separately, because 100% of pa-
tients are female, and specifically examine non–obstetrics and gynecology diagnostic categories. In this data set, students completing the obstetrics and gynecology clerkship reported that 64% of infectious disease encounters and 85% of oncology encounters included discussions regarding gender, whereas only 12% of gastroenterology encounters and 14% of preventative medicine encounters included discussions of gender. It is interesting to note that in the diagnostic categories with sufficient reports to support statistical analysis, teacher gender did not affect amount of gender-specific education. One might argue that medical students do not regularly record encounters. This is not true in the experience of our institution. Third-year medical students have used hand-held computers in the family medicine rotation for the last 2 years, and analysis reveals that they report more than 80% of their patient encounters.3 One explanation for the lack of gender-specific health education in medical school is the lack of knowledge by our teachers. Another hypothesis is that students fail to recognize when a teacher has made a reference to gender. Although our results are disappointing regarding the amount of gender-specific health currently taught in the clinical setting, the use of the PDA represents a unique means of monitoring not only clinical experience but also curriculum modification in response to collected data. REFERENCES
1. Structure and functions of a medical school. Published by the AMA/AAMC Liaison Committee on Medical Education (LCME). www.lcme.org. 2. Association of American Medical Colleges Division of Medical Education. Medical School Senior Graduation Questionnaire–2000. Washington (DC): Association of American Medical Colleges Division of Medical Education; 2000. 3. Bower DJ, Bertling CJ. Using Palm Pilots as a teaching tool during a primary care clerkship. Advanced Education Group. Acad Med 2000; 75:541-2.
Key words: Personal digital assistant, women’s health
Recognizing the need to better incorporate women’s health into our curriculum, the Curriculum and Evaluation Committee (CEC) of the Medical College of Wisconsin established an ad hoc committee to perform a needs assessment. The committee established a set of comprehensive longitudinal competencies that were approved by the CEC. A multi-methods needs assessment was performed to establish the presence of women’s health in the medical school curriculum. Results of the needs assessment revealed crucial gaps in our curriculum with regard to women’s health. Fourth-year students, in focus groups conducted as part of the needs assessment methodology, stated that the majority of their education in women’s health occurred during their clinical years. Because retrospective reports are subject to bias and provide limited insight into actual clinical teaching provided to students during their clerkships, this study was designed to utilize personal digital assistants (PDAs) to obtain a “real time” assessment of women’s health teaching during third-year clerkships.
From the Medical College of Wisconsin, Milwaukee. Supported by Medical College of Wisconsin Learning Resource Grant. Presented as a poster at Central Group on Educational Affairs–Association of American Medical Colleges, Minneapolis Minn, March 15-18, 2001. Reprints are not available from authors. © 2002, Mosby, Inc. All rights reserved. 0002-9378/2002/$35.00 + 0 6/0/127367 doi:10.1067/mob.2002.127367
Material and methods An ad hoc committee of the medical school’s CEC was established to assess the degree to which core competencies in women’s health were addressed in our medical student curriculum. A hand-held computer system was developed to assess the inclusion of the CEC-approved set of women’s health objectives during clinical components (eg, attending rounds, case presentations) of the required third-year medical student rotations. Twelve students (6 women and 6 men) were selected to participate on the basis of their third-year track schedule and prior involvement in medical school–related organizations (CEC, Admissions Committee, Student Assembly). These students were supplied with a PDA, which was pre-loaded with point-of-case software (Five Minute Clinical Consult, Lippincott, Williams and Wilkins, Philadelphia, Pa) and a brief patient log system created by using PenDragon forms (Pendragon Software Corporation, Liberty, IL). One student piloted the system before an orientation session to verify ease of utility and appropriateness of questions. During the 1-hour orientation, students received instruction on how to complete the log for each patient for whom they were primarily responsible. The log included rotation, clinical setting (eg, ambulatory, inpatient), gender of teacher and patient, patient’s diagnosis, and whether gender’s impact on disease was discussed. The students downloaded their logs to a central computer every 2 weeks. Each student signed an informed consent form before participation in the project. S19
S20 Autry et al
Fig 1. Gender discussion by diagnostic category. C-V, Cardiovascular; GI, gastrointestinal; ID, infectious diseases.
Fig 2. Gender discussion by clerkship. Dots, Total encounters. Diamonds, Encounters where gender was discussed.
A senior analyst in the education department extracted 8 months of downloaded data (November 2000-June 2001). Diagnosis, clerkship, whether gender was discussed, and variables including teacher gender and hospital setting were cross-tabulated and analyzed for significance. Chi-square and Fisher exact tests were used as appropriate. Results Students recorded a total of 2690 patient encounters with no major technical difficulties resulting in student dropout or loss of data. The highest diagnostic categories
September 2002 Am J Obstet Gynecol
Fig 3. Diagnostic categories with gender discussion by clerkship. C-V, Cardiovascular.
documented were as follows: obstetrics and gynecology, 638 (23%); cardiovascular, 360 (13%); psychiatry, 331 (12%); gastrointestinal, 310 (12%); pulmonary, 104 (4%); dermatology, 103 (4%); infectious disease, 89 (3%); and neurology, 88 (3%). The top 5 diagnostic categories in which gender was discussed were obstetrics and gynecology, psychiatry, cardiovascular, neurology, and pulmonary. Fig 1 shows the relationship of number of patient encounters in diagnostic categories to number of these encounters in which gender was discussed. Except for obstetrics and gynecology, approximately half of all patients in the top 5 diagnostic categories in which gender was discussed were female. Obstetrics and gynecology, psychiatry, and neurology had sufficient “gender-discussed” encounters to perform further analysis. Forty-six percent of obstetrics and gynecology encounters included gender discussion. Gender discussion was significantly more likely to occur in the inpatient setting (P = .007). Twelve percent of psychiatry encounters included gender discussion, which was much more likely to occur when the patient was female (P = .047) but was unaffected by hospital setting. Five percent of patients with a neurologic diagnosis had gender discussed with no difference by patient gender or hospital setting. There was no significant effect of teacher gender on probability that gender would be discussed in obstetrics and gynecology–, psychiatry-, or neurology-related diagnostic categories. Gender discussion by clerkship was variable (see Fig 2). Cross-tabulation of gender discussion by clerkship revealed that 51% of these encounters occurred in obstetrics and gynecology, 15% in pediatrics, 12% in psychiatry and medicine, 5% in family medicine, 2.5% in surgery, and 1.6% in anesthesia.
Autry et al S21
Volume 187, Number 3 Am J Obstet Gynecol
Fig 3 shows diagnostic categories in which gender discussion occurred by clerkship. For example, 90% of gender discussion in the obstetrics and gynecology diagnostic categories occurred during the obstetrics and gynecology clerkship, 6% during the anesthesia clerkship, and 3% during the medicine clerkship. Among the cardiovascular disease categories, 55% of gender discussion occurred during the medicine clerkship, 25% during the family medicine clerkship, and 11% during the surgery clerkship. On the other hand, during the obstetrics and gynecology clerkship, 12% of gastroenterology encounters, 64% of infectious disease encounters, 85% of oncology encounters, and 14% of preventive medicine encounters included a discussion of gender. Comment In 1998, new guidelines from the Liaison Committee on Graduate Medical Education mandated that clinical experiences be equivalent across sites within the same clerkship and that mechanisms for tracking and validation of clinical clerkship goals and objectives be established at the individual student level.1 Results from the 2000 Senior Graduation Questionnaire from the Association of American Medical Colleges reveal that 25% of students report inadequate instruction in women’s health.2 There have been multiple reports of the successful use of computerized or handheld computer log systems for documentation of student experience.3 This study represents our attempt to use a PDA to assess “real time” clinical experiences in the area of women’s health and ultimately monitor curriculum reform. Our results were disappointing yet revealing from a gender health perspective. Other than obstetrics and gynecology, no diagnostic category included a discussion of gender’s effect on health or disease more than 15% of the time. In clerkships other than obstetrics and gynecology, gender was discussed in only 10% to 20% of patient encounters. One must evaluate obstetrics and gynecology clerkship experiences separately, because 100% of pa-
tients are female, and specifically examine non–obstetrics and gynecology diagnostic categories. In this data set, students completing the obstetrics and gynecology clerkship reported that 64% of infectious disease encounters and 85% of oncology encounters included discussions regarding gender, whereas only 12% of gastroenterology encounters and 14% of preventative medicine encounters included discussions of gender. It is interesting to note that in the diagnostic categories with sufficient reports to support statistical analysis, teacher gender did not affect amount of gender-specific education. One might argue that medical students do not regularly record encounters. This is not true in the experience of our institution. Third-year medical students have used hand-held computers in the family medicine rotation for the last 2 years, and analysis reveals that they report more than 80% of their patient encounters.3 One explanation for the lack of gender-specific health education in medical school is the lack of knowledge by our teachers. Another hypothesis is that students fail to recognize when a teacher has made a reference to gender. Although our results are disappointing regarding the amount of gender-specific health currently taught in the clinical setting, the use of the PDA represents a unique means of monitoring not only clinical experience but also curriculum modification in response to collected data. REFERENCES
1. Structure and functions of a medical school. Published by the AMA/AAMC Liaison Committee on Medical Education (LCME). www.lcme.org. 2. Association of American Medical Colleges Division of Medical Education. Medical School Senior Graduation Questionnaire–2000. Washington (DC): Association of American Medical Colleges Division of Medical Education; 2000. 3. Bower DJ, Bertling CJ. Using Palm Pilots as a teaching tool during a primary care clerkship. Advanced Education Group. Acad Med 2000; 75:541-2.