University of Virginia Health System

1. The Academy of Distinguished Educators at the University of Virginia (ADE); Hilary Sanfey on behalf of the ADE

The ADE was established by the Dean of the School of Medicine in 2003 to provide an organizational structure that would recognize, reward, promote and develop excellence in medical education. The members, organized into a number of committees, conduct the work of the academy under the leadership of the Senior Associate Dean for Faculty Development. The chairs of the committees meet monthly as a steering committee.
Founding Members
The characteristics and perceptions (see Table) of the 84 founding members (FM) of the ADE were determined by an IRB approved anonymous survey (response rate 78.0%). All FM were recipients of the Dean’s Teaching Award or equivalent and included faculty from clinical (70%) and basic science departments. 80% of FM devote more than 25% of their time to educational activities: The mean percentage of educational time devoted to teaching medical students was 37.0% and 36.0% for residents. 37% of teaching takes place in a clinical setting, and 22% in classrooms. 73.0% of FM were male, 59% aged 50 years or older, and 70.0% were tenured. 54.0% were clinician educators and 19.0% were on investigator tracks.
Perceptions of Founding Members

Activities and Programs
The ADE Steering Committee has developed an educator’s portfolio to document educational activity. Excellence in one or more of the following areas will be required for future membership: direct teaching, curriculum development and assessment of learner performance, advising and mentoring, educational administration and leadership, and educational research. Currently 10% of school of medicine faculty, belong to the ADE and12 new members have been added since it’s inception, Other ADE accomplishments include allocation of grants for educational research, faculty development, a peer teaching evaluation program, a visiting professorship and an Educational Research Day.
Conclusions
The characteristics of the founding members reflect an imbalance of senior educators as a result of the founding criteria. We anticipate this will change as senior members retire and more junior faculty members are appointed and that ADE membership will be an advantage in the promotion process. While it is early to make definitive statements about the impact of the ADE we expect that by bringing together the school's most talented and dedicated faculty and providing support for educational endeavor the academy has created a mechanism for increasing the recognition of teaching contributions of both academy members and the teaching faculty at large, fostering educational innovation, and providing a forum for the exchange of ideas related to medical education that cross departmental and institutional lines.

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2. Academy of Distinguished Educators’ Medical Education Research Grant Program; Jerry Short, Ph.D.

The Academy announces its third round of grants for research in medical education. The Request for Proposal and a list of previously funded projects are described in the poster.  This year support is limited to research related to the education of undergraduate medical students (UME).  The proposal deadline is April 14, 2006.

Types of Research Funded:  Both quantitative and qualitative research projects are appropriate, as are meta-analyses of the medical education research literature.  Projects involving the development of new educational materials must have a strong evaluation/research component.
Abstracts of previously successful applications are available at:
http://www.healthsystem.virginia.edu/internet/ade/

Research topics:  Some areas of interest include, but are not limited to:
clinical skills development
educational outcomes
medical students and duty hours
professionalism education
instructional technology
web-based instruction
game technology in med education
health care economics
impact of curriculum changes         
medical errors
medical legal issues
teamwork in patient care delivery
medical student selection
ethnic and cultural disparities
patient simulation
assessment
communication
curriculum integration

These areas of interest should not discourage faculty from developing proposals in other areas.  Applicants are encouraged to attend the faculty development program sessions related to medical education research grants.

Proposal Format:  Please include these headings and sections in your proposal:

1. Title of Project
2. Abstract
3. Background
            4. Goals of the project
            5. Research plan with defined measurable outcomes
            6. Plans for publication and dissemination of results
            7. Investigator biosketch (2 pages)
            8. Letter of support from department chair or division head
            9. Budget (may include investigator effort, support personnel, supplies)

Proposal Length: 5 page maximum (not including biosketch, letter of recommendation, and budget)

3. Silent Women: Gender Differences Seen in the Number of Questions Asked During Lectures in the First Year School of Medicine Classroom at the University of Virginia; Corinne Savides,  UVA School of Medicine, Class of 2009

Research Question: Is there a significant difference between the number of questions asked by women and those asked by men during lectures in the first year School of Medicine classroom at the University of Virginia?

The number of questions asked during regular class lectures, along with the corresponding genders of the students asking questions, was recorded throughout the duration of a three-week intensive genetics course in the first year class of the School of Medicine at the University of Virginia.  Regular lectures were defined as any lecture open to the entire class where new, testable information was presented.  In order for a question to be included, the student had to successfully gain the attention of the professor either verbally or by a raised hand and then receive a response.  Once a student was recognized, follow-up questions within that period of recognition were not counted separately.

Results: Women asked significantly fewer questions per lecture (M = 1.56, SD = 2.18) than did men (M = 5.26, SD = 3.58), t(54) = 5.16, p<.001 (one-tailed). Out of 232 questions that were asked during Medical Genetics, only 53 (23%) were asked by women (Figure 1). 
  

Conclusions: Gender differences are present in the classroom, and the medical school classroom is no exception.  Faculty, administrators, and students should be aware of these differences as they seek to improve medical education at the University of Virginia.

Source of Funding:  Self-funded

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4. Clerkship Clinical Skills Education Project: Student Skills Assessment Data, Pilot Year 2004-05; Eugene C. Corbett, Jr., M.D. (PI),                 Elizabeth B. Bradley, Ph.D., Karen Maughan, M.D., Veronica Michaelsen, M.D., Nancy Payne, M.D., Xin-Qun Wang, M.S.

Background: The purpose of the Clerkship Clinical Skills Education Project is to facilitate curricular innovation that enhances the clinical skill performance development of medical students. One element of this project is assessment of students’ ability to perform selected basic clinical skills during the clerkship year. Basic skills include those which all students are expected to perform proficiently prior to graduation. Skills to be assessed are recommended by diverse faculty who participate in the design of objective structured clinical examination (OSCE)   exercises. Additional faculty participate as assessment observers and assist in student performance evaluation and standard setting. The assessment exercises are designed to be formative so that at each station, the student has the opportunity to subsequently discuss their performance with faculty and standardized patients. The intent is not only to provide each student with an assessment-driven clinical skill education experience, but to also inform efforts to improve the curriculum by measuring the collective skill performance ability of medical students.

Research Questions: During the initial pilot year (2004-05) we explored the following questions:

1. How well did students perform the assessed skills?
2. Did the students’ skill performance change when assessed 4 months later?
3. How often did the student have the opportunity to practice these skills?

Research Design: Students were assessed regarding eight basic clinical skills in December 2004 and April 2005. Descriptive statistics were used to describe the overall group performance on each skill. For question number two, a mixed effects model was used to compare the mean difference in April and December total scores between the different groups. The response variable was the difference in the total clinical skills scores between April 2005 and December 2004 evaluated by different groups (Faculty, Patients, and Students).  The model was also adjusted for the baseline measurements (the total scores in December 2004).  For subgroup analyses a two-sample t-test was used to test if there was a difference in the total scores evaluated by faculty group between students who took both December and April exams and students who took only April exam. The type I error rate was specified at a significant level of 0.05. All statistical analyses were performed using the SAS Version 9.1 (SAS Institute Inc., Cary, NC).

Results: The Pilot Year of the assessment program was completed in June 2005. One hundred twenty five of the 137 students in the Class of 2006 completed formative assessments either one or two times. Of these, 77 students were tested two times, completing the same four objective structured clinical examination cases in both December and April. For all eight skills assessed in December, the mean faculty observer performance score was 84% or lower (range 46-84%). In April, all observer scores were 93% or lower (range 60-93%).

The mean total scores evaluated by different groups in April were significantly higher than in December for four stations. The students who took both December and April exams scored significantly higher on two stations than the students who took only the April exams. Also, although not statistically significant at the 0.05 level, it seemed that there was a trend toward a better performance for students who took both December and April exams compared to students who took only the April exam in five other clinical skills.

Finally, students reported limited practice opportunity. For 6 of the 8 skills assessed the majority of students reported practicing the skills ten or fewer times in a clinical setting.

Conclusions: Students’ clinical skill performance ability for these eight basic skills is less than faculty expectation. The reasons for this are undoubtedly multifactorial and further study is needed. Preliminary data indicates that it is, at least in part, due to inadequacy in skill performance practice opportunity.

Source of Funding:  HRSA-BHPR Predoctoral Primary Care Education Grant

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5. “Becoming a Clinician” -- An Introduction to Clinical Professionalism for Medical Students
Christine M. Peterson, M.D.  [Associate Professor of Clinical Obstetrics and Gynecology, Assistant Dean for Medical Education, Director, Gynecology Clinic, Department of Student Health]
Marcia Day Childress, Ph.D. [Associate Professor of Medical Education, Associate Director, Center for Humanism in Medicine]
Margaret E. Mohrmann, M.D., Ph.D. [Associate Professor of Religious Studies, Pediatrics, and Medical Education]

Research question: Does a ceremony at the outset of the clerkship year influence students’ understanding and practice of clinical professionalism?
            In medical education circles, debate swirls about whether and how best to teach the as-yet-poorly-defined cluster of knowledge, skills, and attitudes referred to as “professionalism.” Joining this debate, we sought to direct the attention of medical students at the University of Virginia toward some of these qualities just as the rising third-year class begins fulltime involvement in clinical work. In June 2005, we developed a brief ceremony for the Class of 2007 called Becoming a Clinician that is modeled on and recalls the Convocation these students attended when they entered medical school and began their classroom studies two years previously. As with the earlier Convocation, Becoming a Clinician capitalizes on the students' eager anticipation of a new phase of their education, calls attention to crucial shifts in what will now be required of them as young clinicians, and at once solemnizes and celebrates this important transition in their professional lives. Becoming a Clinician makes clear to students that they are leaving the values and priorities of classroom performance behind and are expected to assume those professional attributes, attitudes, and behaviors that mark excellent humanistic clinical practice, especially respect, compassion, integrity, self-reflection, teamwork, and primacy of concern for and service to the patient.  
With generous financial support from the Arnold P. Gold Foundation, we organized a ceremony that featured five activities: (1) recognition (induction into the Gold Humanism Honor Society and monetary awards) of several resident physicians who had been cited for their humanistic qualities by the previous class of medical students; (2) an inspirational talk by a resident who had received a Humanism in Medicine award while a UVA medical student; (3) recitation by students and their teachers of covenants written specifically for this occasion as an extension into the clinical realm of the covenants recited at Convocation; (4) presentation to students of pocket-size blank notebooks, with encouragement that they write about their clerkship experiences through the year (as the physician who spoke at the ceremony had done during her clerkship year); and (5) a reception for the class and their teachers.

Research design: Qualitative analysis of responses to a brief questionnaire to be administered one year after the Becoming a Clinician ceremony. We will ask students in the Class of 2007 whether they had occasion to recall the ceremony or the covenants at any time(s) during their clerkships, and if so, to tell us what happened and whether the experience was affirming or discouraging with respect to professional behavior. We will also ask them whether they used their pocket notebooks for reflective writing about their experiences and whether they would be willing to share their writings with us.

Results and conclusions: pending administration of questionnaires and analysis of responses.

Source of funding: Arnold P. Gold Foundation

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6.  The Surgical Pimp-Off: The Evolution of Medical Student Education and the Surgical Team; T. Brett Reece, Brendon M. Stiles, Robert A. Garwood, Michael G. Hughes, Joseph J. Dubose, Leo Gazoni, Philip Smith, Traci Hedrick, Charles M. Friel, Robert G. Sawyer, Curtis G. Tribble

Contact information: T. Brett Reece
HSC Box 801359
Charlottesville VA 22911
Tbr5q@virginia.edu
(434)465-5131

Objectives: The difficulties completing the workload within duty hour restrictions detract from resident availability for student education on the surgical services. This is compounded by the post-call absence of both chief residents and students from teaching rounds. We felt the team aspect of the surgery was being lost, so we hypothesized that development of a team based competition, or Pimp-Off, could bring back the team cohesiveness, while promoting surgical education.

Materials and Methods:  The Pimp-Off was devised as an intellectual competition among three general surgery teams. Following the surgical rotation, the students completed an anonymous survey of their opinions on the significance of the Pimp-Off on their learning and their sense of team.  Answers on a 5-point Likert scale ranged from "strongly agree" to "strongly disagree".

Results: Sixty-eight percent (19/28) of participating students responded to the survey. Of these, 90% ("strongly agreed" or "agreed") felt that the competition inspired them to read more.  79% felt pimping was an effective teaching format. 68% believed this competition inspired them to teach others. 90% of the students felt that preparing for the Pimp-Off gave them a sense of team spirit. With respect to core competencies, 84% felt that the Pimp-Off addressed medical knowledge, while 68% felt it addressed practice based learning.

Conclusions: Despite strains on teaching from duty hour restrictions, the Pimp-Off stimulated student learning and improved team cohesiveness during the surgical clerkship. The Pimp-Off has strengthened the surgical clerkship at our institution as a part of the progression of medical education.

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7.  Comparison between Interactive Web-based Learning and Traditional Textbook Method as   Educational Tools: A Randomized Prospective Trial; Cook CD, Ciambotti JM, Nandalur KR, Gay SB

Purpose:  Interactive web-based learning has rapidly emerged as a readily available and usually free method of education for medical students and residents.  The purpose of our study was to compare this new method against traditional textbook learning to determine its value as an instructional tool.

Materials and Methods:  We recruited a total of 30 senior medical students at the University of Virginia (UVA) to take a 50 question multiple-choice test at the beginning of their rotation.  Fifteen random students then were instructed to read the pediatric radiology fundamentals textbook used at our institution, and fifteen were instructed to read the UVA Pediatric Radiology Website.  After a period of approximately 30 days, all enrolled students retook the test, which covered material fairly from both methods.  We compared improvement on the pre and post-test using a paired t-test and the difference in improvement between web-based and textbook learning using the Student's t-test.

Results:  Students using either the book or website showed significant improvement on the post-test compared to the pre-test with both P values <0.001.  Notably, there was a tendency for participants using the website to improve more from the pre to post-test than those using the book (P=0.105).

Conclusion:  The University of Virginia Pediatric Radiology website and textbook are excellent educational tools, as evidenced by the significant improvement by students on the test after their use.  Given the greater improvement using the website and easy accessibility, this method may be more conducive to learning.

Funding: Internal

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8. National Trends in Histology Laboratory Teaching; Robert A. Bloodgood (Dept of Cell Biology, University of Virginia School of Medicine), Robert W. Ogilvie (Dept of Cell Biology and Anatomy, Medical University of South Carolina)

Research Question/Hypothesis:  Our goal was to examine national trends in the amount of time spent by medical students and faculty in the histology laboratory setting and the trends in use of various tools for histology laboratory teaching and learning.  Our hypothesis was that the recent availability of various types of computer-based instructional tools (in particular Virtual Microscopy and Virtual Slides) is changing the way that medical students learn histology and is affecting the amount of time that medical students and faculty spend in the formal histology laboratory setting.

Description of  research design:  A detailed survey was designed and then distributed (via Survey Suite) to histology course directors at all US medical schools during February 2005.  Approximately 2/3rds of schools (n=82) responded.

Results and conclusions:

• 1. The amount of faculty-assisted scheduled histology laboratory time has declined from an average of 46 hrs in 1999 to 37.4 hrs in 2005. 31.7% of respondents indicated that the total hours each student participated in faculty-assisted lab instruction has declined during the past 3 years; similarly, 30.5% of schools indicated a decrease in total faculty hours devoted to histology laboratory instruction. In both cases, most of the remaining schools reported no change with few schools reporting an increase in either medical student or faculty hours.
• 2. In terms of the use of various instructional technologies in the histology laboratory, we identified several trends: A) There has not been a major decline in the number of medical schools that utilize microscopes and glass slides for laboratory instruction, B) There has been a dramatic increase in the number of schools using Virtual Slides and other forms of Computer-Aided Instruction (CAI).

C) Most schools are choosing to use a mixture of various tools in their histology laboratory instruction (including microscopes and glass slides as well as Virtual Microscopy and/or other forms of CAI).  Other recent research suggests that the choice of instructional technology is not a major variable in medical student performance in histology lab examinations. Respondents to our survey emphasized the importance of the involvement of qualified faculty as the most important determinant of the quality of medical student laboratory education.

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9. An Intervention for Teaching Smoking Cessation Counseling to Medical Students; Uzma M. Ali, MD (Clinical Instructor and Fellow, UVa Department of Family Medicine), Scott M. Strayer, MD, MPH (Assistant Professor, UVa Department of Family Medicine)

Hypothesis: There is a demonstrated need for smoking cessation counseling instruction and the incorporation of point-of-care technology to teach behavior change interventions to medical students.

Description of Research Design: The purpose of this research project is to develop and evaluate an educational intervention to teach medical students behavioral counseling skills to address smoking cessation behavior. 

Students will receive instruction in Motivational Interviewing (MI) and a randomized controlled trial will be conducted to evaluate the efficacy of using an innovative handheld computer tool that assists them with assessing stages of change, using MI techniques and the use of appropriate stage-based interventions for smoking cessation. Counseling skills will be assessed via standardized patients (SPs) and independent observers. This project will develop an Educational Smoking Interventional Tool (E-SMOK-I.T.) to assist medical students with smoking cessation counseling. The tool will be evaluated in the randomized control trial in conjunction with a workshop on Motivational Interviewing to teach smoking cessation counseling skills to medical students. A qualitative evaluation of the workshop and handheld tool interventions to teach smoking cessation counseling will be conducted.

Results and Conclusions: The research design and preliminary assessment instruments will be presented along with mock-ups of the E-SMOK-I.T. tool that is currently in development.

Sources of Funding: American Cancer Society Cancer Control Career Development Award for Primary Care Physicians #CCCDA-05-160-01; HRSA Training in Primary Care Medicine and Dentistry Grant #D55HP00238

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10. Web-Based System of Instruction and Self-Evaluation In Critical Thinking and Technology Assessment; Bryan S. Jeun SMD 2008, Kimberly E. Applegate, M.D., Spencer B. Gay, M.D. University of Virginia Health System, Charlottesville, VA

Purpose:  The aim of this website is to teach members of the medical community key aspects of technology assessment and  the critical thinking process in evaluating scientific publications.

Methods:  We have developed a web site instructing medical students and residents in basic principles of the critical thinking process using examples from the literature.  Topics such as believable research and how it pertains to validity, reliability and generalizability as well as common sources of bias are included.  The hierarchy of research is described, as well as methods of study design. Following each section, questions reviewing these principles are presented. On completing the website, a quiz for self-assessment and documentation of competency is provided. We hope that the user will begin cultivating critical thinking skills and incorporating them into practice.

Conclusion:  Web-based instruction in the basics of critical thinking and technology assessment can serve as a method of instruction and can be used for distance learning of this material. This website can help fulfill competency requirements in an important research aspect of Systems-Based Practice.

Funding: Hospital Educational Resource Development Funding (Mr. Ed Howell)

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11. Developing An Electronic, Multi-Media Faculty Development Program For Community Preceptors of a Family Medicine Clerkship; Karen Maughan, MD, Lisa Rollins, PhD,  John Jackson, PhD, John Gazewood, MS, MD (Department of Family Medicine, University of Virginia)

Our Department of Family Medicine currently maintains a preceptor pool of approximately 315 community-based family physicians. These preceptors play a significant role in the education of our predoctoral students throughout the four-year medical school curriculum. Although the instructional contributions of our community preceptors are significant, the great variety of sites poses challenges in effectively communicating instructional expectations and continuing to expand the preceptors' instructional repertoire. Our preceptors are located across the state and as such, they are isolated from each other and from many of the local resources within our Health System. This has been a particular challenge for our Family Medicine Clerkship, as most of our community sites are located away from the Medical School, some as far as 5 hours by car. In a variety of attempts to reach our preceptors, we have hosted evening faculty development sessions is areas central to several of our preceptors,  offered similar sessions at semi-annual CME conferences sponsored by our state Academy of Family Practice,  in adjunct to popular local conferences, and at annual "preceptor appreciation" week-ends conducted by our institution. While these sessions have been highly rated by the attendees, the overall numbers of attendees has been quite small. We also realize it can be difficult for preceptors to leave their practices because of issues related to patient coverage and potential lost revenue.

In response to these challenges, we developed a new method to access our community preceptors. Emphasis was placed on developing an approach that was flexible, relevant, interactive, and enabled preceptors to receive the necessary information with minimal inconvenience to their practice and patient populations. These efforts resulted in a Web- and CD ROM-based Preceptor Development Program that is organized in a series of discrete educational modules that can be completed as time allows. Since many preceptors do not have computers with the broadband connectivity needed for delivery of multimedia material such as video clips, this CD also utilizes Web-site connectivity to enable widespread access and operation from any computer that is CD-ready with WEB access.

Description of research design: The Web- and CDRom-based Preceptor Development Program was developed and distributed to a pilot group of 10 interested preceptor volunteers for their evaluation.  The program was evaluated for clarity and usefulness of material, ease of navigation, and overall value to the preceptors.  The evaluation included both Likert scale and open-ended questions.  The results of the evaluations will be used to revise and improve the program.

Results: At the time of writing, not all evaluations have been received.  Preliminary results show that our preceptors view the program very favorably.   They find the program easy to use.  The time required to complete each module seems reasonable.  The respondents indicate they would like more video clips.  One identified challenge is to be careful not to make unrealistic recommendations of the preceptors such as decreasing the number of patients seen on days when teaching a student.  Another challenge is to find balance in directing content to both new and seasoned preceptors.  All respondents indicated they would like CME credit to be made available for completing the program.  A full analysis of responses will be reported once received.

Conclusions: Family Medicine community preceptors are excited about this faculty development Web- and CDRom-based program that provides discrete, interactive modules that can be completed as the preceptor's schedule allows.  This program could be modified to teach principles and practical aspects of teaching for other audiences such as resident physicians.

Source of funding: HRSA Family Medicine Predoctoral Training Grant to the University of Virginia (grant # 5D16HP00134-03-00)

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12. Assessing the accuracy of predictions of eventual rural practice using different definitions to classify medical school applicants as having a rural upbringing; John A. Owen, Ed.D., M.S. (UVa Center for the Advancement of Generalist Medicine), Beth A. Bailey, Ph.D. (UVa School of Medicine),
Gregory F. Hayden, MD (Division of General Pediatrics, UVa School of Medicine)

Hypothesis/Research Question: Many rural areas are medically underserved, and policy makers and educators face the difficult challenge of devising cost-effective ways to increase the number of health care providers in rural areas.  Studies to understand why physicians choose to practice in rural areas have examined the possible effects of several personal characteristics.  A "rural upbringing" has been positively associated with physicians' practicing in rural areas in several studies.  However, this positive association has been difficult to operationalize because the word "rural" has multiple and sometimes conflicting definitions.  A number of classification systems recently have been developed by the Office of Management and Budget and by the Economic Research Service to refine the definition of "rural."  It is unclear which of these new systems may be the most accurate in identifying future physicians whose rural upbringing may predispose them to rural practice.  The purpose of this study was to determine whether the likelihood of rural practice differed according to different definitions of "rural" used to categorize the geographic upbringing of applicants who entered the UVa School of Medicine in 1990-95 and graduated in 1994-99.  The influences of gender and career plan at matriculation upon rural practice were also explored. 
Research Design/Sources of data: From each applicant's record we recorded:  gender; name, city, and state of the high school from which the applicant graduated; address of the college or university from which applicant received his/her bachelor's degree; and permanent mailing address at the time of application.  The rural upbringing of each applicant was assessed by coding these three addresses using four definitions of rural: (1) Non-metropolitan-Metropolitan,  (2) Rural-Urban, (3) Rural-Urban Continuum Codes, and (4) Rural-Urban Commuting Areas.  All four definitions were derived from 1990 census data.  A direct survey question included on the form mailed to each graduate and used to verify practice addresses was worded as follows: "Did you grow up in a rural area (Yes/No/Not Certain)?"  Whenever available, stated career preferences on the Association of American Medical College's (AAMC) Matriculating Student Questionnaire were coded into one of the two categories: generalist (family medicine, general internal medicine, and general pediatrics) or specialist. 
     The outcome measure was rural practice.  The same four definitions of rural were used to assess the rurality of practice locations. For each assessment of rural practice, the same definition of rural was used to categorize both the background and practice addresses, e.g., background addresses were categorized using the rural/urban definition when practice addresses were assessed using the rural/urban definition.  Census 2000 versions of these definitions were used to categorize the practice addresses to better approximate the time the practices were established. 

Data Analysis: Univariate analysis was completed for each of the following: four definitions of rural as applied to each of the three applicant addresses; "grew up rural" self-description; gender; and students' career preferences at matriculation using generalist careers as the reference group.    Variables were considered predictive of rural practice if they were significant at the 0.05 level.  Logistic regression models were used to predict the simultaneous effect of applicant addresses, "grew up rural" self-description, and gender on the probability of practicing in rural areas.  Due to the amount of missing data for the students' career preference variable, the effect of this variable was assessed in a secondary analysis.  Significance was set at the 0.05 level.  Odds ratios (ORs) were calculated to approximate the probability that individuals practicing in rural areas had a particular rural background and specific characteristics as compared to those individuals practicing in urban areas; ORs over 1.00 indicated an increased likelihood, and ORs under 1.00 indicated a decreased likelihood.   

Results and conclusions: In univariate analyses, the high school, college, and permanent addresses were all somewhat predictive of rural practice using one or more definitions of rural.  In the multivariate analysis, only the "grew up rural" self-description was predictive of rural practice location using three of the definitions of rural.  In a secondary analysis, the "grew up rural" self-description and applicants' career preferences at matriculation were the strongest predictors of rural practice.   We concluded that readily available addresses were somewhat accurate in predicting rural practice. In a multivariate analysis, physicians' self-description about having grown up in a rural area was the best predictor of rural practice.  Recruiting more applicants who match this definition of rural background should increase the number of rural physicians.
Source of Funding UVa Academy of Distinguished Educators 2004 Small Grants Program. 

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13. THE CLINICAL HEALTH ECONOMICS SYSTEM SIMULATION (CHESS): PRACTICAL LEARNING FROM PLAY J.D. VOSS (University of Virginia), M.L. MINTZ (George Washington University), J.M. JACKSON (University of Virginia), J.M. SCHECTMAN (University of Virginia). 

RESEARCH QUESTION: A paucity of methods exist to teach medical trainees about the structure and financing of the US health care system despite requirements from graduate and undergraduate accrediting organizations. CHESS is an interactive cognitive simulation for learners working in teams paid fee-for-service (FFS) or capitation (CAP) to examine toss-up medical decisions and select treatments of variable resource intensity. CHESS provides feedback about costs and physician income so that learners may see how differences in payment incentives and cost may influence treatment selections and the perceived value of health care services delivered. We hypothesized that participation in CHESS would produce significant and meaningful changes in attitudes, belief and self-reported knowledge for learners.

RESEARCH DESIGN: We conducted 29 workshops with 523 medical students and internal medicine residents participating in small group exercises at institution 1 with a single large group activity at institution 2. Learners completed an anonymous 32 item pre-post questionnaire including 6 items adapted from a previously published survey. Changes in response to these 6 items, measuring attitudes and beliefs about health economics, were prospectively identified as a proxy for measuring learning from participation in the simulation. For each question (see table) learners selected 1) capitation, 2) fee for service, 3) no difference or 4) "I don't know" as a response pre- and post- CHESS. Pre-post changes in belief were examined using McNemar's test for paired data. Post simulation, learners also rated how much they learned from the seminar and their preference to learn this information in simulation vs. lecture format.

RESULTS and CONCLUSIONS: 79% of participants completed the test instrument. The final sample consisted of 88% medical students and 12% internal medicine resident reponses. Participants recorded high mean (4.4) and median (5) scores of learning (1-learned little, 5-learned a great deal), with slightly higher mean scores for residents than medical students (4.6 vs. 4.3, Mann-Whitney U p value = 0.004). Trainees participating in small groups rated learning more highly (mean 4.4, median 5) than in the large group (mean 3.6, median 4, Mann Whitney U p <0.001).The percent of participants changing their response (our learning proxy) after the seminar for the 6 questions are listed in the table. Post CHESS, 81% of learners indicated that they believed that capitation was more likely to deliver the greatest value for money spent but twice as many learners (43%) expressed a personal preference to practice under FFS vs capitation. Ninety percent of trainees preferred learning this information in simulation format. CHESS is a useful and engaging method for learning and applying health economics concepts that leads to significant changes in beliefs and knowledge. Graduate and undergraduate medical learners indicated strong preferences for simulation format.

SOURCE OF FUNDING: This work is primarily supported by a grant from the UVA Innovations in Graduate Medical Education Program with additional funding from the Health Resources and Services Administration, Gene Corbett, MD (Principal Investigator)

Percent of Learners changing response after playing the CHESS simulation:

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