Chronic illness needs educated doctors: An innovative primary care training program for chronic illness education

Abstract

Background: Medical educators need proven curriculum innovations that prepare trainees for the expanding number of patients with chronic illnesses.

Purpose: We describe and evaluate the effectiveness of a chronic illness training program, Chronic Illness Needs Educated Doctors (CINED).

Method: Forty-seven trainees completed four instructional components: (1) measurements of the health-related quality of life of patients with chronic illnesses; (2) didactic sessions in which they described chronically ill patients and their care; (3) written narratives describing the trainees’ reactions for these patients; and (4) portfolios offering evidence of chronic illness learning. We measured the accuracy of the trainees’ clinical skills at the end of CINED with an objective standardized clinical exercise (OSCE).

Results: Forty-seven trainees scored the perceptions of mental and physical health of 414 chronic illnesses patients. In 47 didactic sessions and 93 written narratives, the trainees explained the relationship between the scores and their clinical observations. Accurate differential diagnoses of and communications with chronically ill patients were observed in an OSCE by standardized patients. The trainers rated 13 of the trainees’ chronic illness portfolios as excellent and the remainder satisfactory.

Conclusion: Initial evaluations suggest that the CINED is an effective curriculum for promoting chronic illness learning among trainees.

Introduction

Each year, more than 1.7 million individuals worldwide die of chronic illnesses, which are defined as diseases that do not resolve spontaneously but are often resolved or prevented by lifestyle changes (Murray & Lopez 1996). By 2020, chronic illnesses will be responsible for an estimated 80% of the global disease burden worldwide (Darer et al. 2004). The World Health Organization (WHO) 2010 analysis of its member states shows that low and middle income countries will bear an increasingly large portion of the burden of chronic illnesses (Alwan et al. 2010). Despite these findings, training in most medical schools and schools of public health do not effectively address or keep pace with the increasing incidence of chronic illness (Yech et al. 2004). Recognizing this, the Association of American Medical Colleges in 2006 called for a shift in the focus of medical school training to long-term disease management in ambulatory settings (doctors’ offices and clinics), the environments in which new physicians most often practice. Thus, it is not surprising that primary care leaders are calling for the rapid redesign of medical school curricula and patient management modes to emphasize training in the care of patients with chronic disorders is not surprising (Jerant et al. 2005; Stevens & Wagner 2006; Nieman 2007; Whitcomb 2007; Huddle & Heudelbert 2008).

In a study conducted at a publicly funded clinic used as a primary care training site, we found that chronic illness had a powerful negative impact on the perceived mental and physical well-being of pre-geriatric patients. Specifically, our patients’ Short Form (36) Health Survey (SF-36) health-related quality of life (HRQOL) index scores were a third lower than national norms (Cheng et al. 2003). As shown in an earlier study, these low scores place our patients at increased risk for morbidity and mortality (Hemingway et al. 1997). Our faculty at The University of Texas Medical School at Houston were prompted by these findings to design, implement, and evaluate the effectiveness of Chronic Illness Needs Educated Doctors (CINED), an innovative educational program for instructing trainees to care for patients with chronic illnesses (Nieman 2007). Over a 3-year period (2005–2008), a team from family medicine faculty having significant experience in establishing chronic illness education programs designed the CINED activities. The team focused upon engaging trainees behaviorally and cognitively as active learners.

In this article, we describe and evaluate the initial effectiveness of the CINED innovation. Our goal is to describe CINED's four instructional components, the program's curriculum materials, and the quantitative and qualitative evaluation methods that we used in making program decisions. Year 1 was dedicated to designing, field testing and improving each component. We also determined the responsibilities of the CINED faculty for the curriculum and its evaluation. In years 2 and 3, we refined the curriculum materials and evaluated the learning artifacts in the trainees’ chronic illness portfolios. These portfolio artifacts provided objective evidence of the effectiveness of each CINED curriculum component as well as the overall program.

Table

Practice points

Learning how patients’ perceptions of chronic illnesses affect their mental and physical function is important for physicians. A learning portfolio of artifacts – papers, presentations, case summaries, tests, etc., can be used to provide evidence of ongoing chronic illness training and accomplishments. The CINED program offers innovative ways to begin promoting chronic illness education.

Methods

Participants

Sixty family medicine trainees, including all house staff in the Family Medicine Residency Program at The University of Texas Medical School at Houston, participated in the CINED-based training. The activities described below were incorporated for 3 years into the regular residency curriculum that is available online (The University of Texas Health Sciences Center at Houston 2010). Forty-seven of the 60 trainees, namely, all trainees who were enrolled in the residency during CINED's final 2 years, became program participants. The results described below pertain to these 47 trainees. Thirteen additional trainees, who assisted us with designing and testing the program during its first year, were excluded from our analyses. Although the CINED program was endorsed by the faculty in the Department of Family and Community Medicine at The University of Texas Medical School at Houston, the department did not include CINED activities in making decisions about passing or graduating trainees.

Scope of the CINED program

The goal of the CINED program was that trainees successfully completed the following four curricular components that received approval from the University of Texas Health Science Center at Houston's Internal Review Board: (1) measurement of HRQOL directed at engaging trainees in assessing the functional mental health and well-being of patients with chronic illnesses; (2) didactic sessions describing the patients’ chronic illnesses and perceptions of those illnesses and the care they received; (3) narrative reflections describing the trainees’ perceptions of chronic illness and caring for patients with such illnesses; and (4) chronic illness portfolios of documents providing evidence of achievements resulting from the CINED-training. In addition, trainees were charged with participating in an objective standardized clinical exercise (OSCE) that would measure their general chronic illness communication and physical examination skills at the close of the program.

When each academic year began, the trainees were provided with universal serial bus (USB) flash drives containing required learning documents. As illustrated in Figure 1, the flash drive provided guidelines for documenting their ongoing CINED learning program.

Figure 1. Guidelines for the CINED program's electronic chronic illness portfolio.

Measurement of HRQOL

HRQOL refers to persons’ perceptions of their mental and physical health over time. The Centers for Disease Control and Prevention have used measures of HRQOL tools to track reactions to chronic illness (The Center of Disease Control 2010). These measures have not been used generally as a curriculum tool for teaching and learning about chronic illness. The extensive literature on the SF-36 shows that it is reliable, valid, and easy to administer in a clinical training setting; furthermore, it is available in English and Spanish (Ware et al. 2007). The SF-36 was selected as a practical tool for stimulating our trainees’ chronic illness learning in this study. Specifically, trainees were asked to use it to gain insight into patients’ perceptions of their mental and physical health. During the CINED intervention, an online version of the SF-36 became available, and it facilitated the rapid scoring HRQOL and delivery of feedback on the patients to the trainees (AmIhealthy.com Smart Measurement System 2010).

The SF-36 has been widely used in research to quantify patients’ physical and mental reactions to chronic illness and it provides comparable information about chronic illnesses in a variety of populations. In general, responses to the SF-36 inventory resulted in two key component scores: a physical component score and a mental component score. A norm of 50 indicates that a patient's reaction to his or her condition of chronic condition is equal to the national average. No evidence in the literature of use of the SF-36 by other primary care programs to stimulate chronic illness training was found. Trainees were asked to download de-identified SF-36 scores for their patients. These scores served as evidence that the trainees had administered the SF-36 and reviewed the HRQOL of their patients. Documentation of at least 10 patients with chronic illness was expected from each trainee over the 3-year training period. Documentation of at least 10 encounters was expected from each trainee. We summarized of the total number of administrations of the SF-36 and sent the results to each trainee.

Workshops and didactic presentations

During the 3-year training period, the trainees participated in bi-weekly workshops and didactic sessions with extensive research, theory, and practice underpinnings in behavioral medicine described by Glanz et al. (2001). In the workshops, that we designed, the trainees learned to administer the SF-36 to patients with chronic illnesses and to interpret the resulting scores for specific patients. Guided by our behavioral medicine faculty, who joined the CINED teaching team, the trainees also practiced health behavior and education techniques, such as motivational interviewing and case conferences.

We gave CINED trainees the responsibility to participate in the design and delivery of the didactic sessions. In the first year of the training period, the trainees, who had little experience in administering the SF-36, gave didactic presentations on the national guidelines for managing selected chronic illnesses. In the second and third years, trainees gave didactic presentations on (1) information about their patients’ chronic illnesses and SF-36 scores, (2) relevant literature to the patients’ specific conditions, (3) interventions made, (4) patients’ responses to the interventions, and (5) outcomes achieved and applications of chronic illness intervention to their future practices. The trainees were told that each didactic session should include a single PowerPoint presentation that described the patient's chronic illness and demonstrated the trainee's “best efforts” in applying the SF-36 to managing the illness. We used the legal term “best efforts” to denote that the trainees would attempt to achieve the highest quality results within the context of the residency program. (BusinessDictionary.com 2010). All of the second- and third-year trainees gave presentations that described their patients’ chronic illnesses, their care, their perceptions of the condition or conditions, and their perceptions of the care they received. All trainees downloaded their presentations to the Reflections and Presentations folder in their portfolios (Table 1).

Table 1.  20 Chronic illness topics presented at 47 didactic sessions by family medicine trainees, academic year 2007 and 2008^a

Chronic problems
Anemia	Hypercholesterolemia
Atrial fibrillation	Hypertension
Arthritis	Hypnologic gastritis
Chronic obstructive pulmonary disorder	Hypothyroidism
Chronic pain	Metabolic syndrome
Chronic tobacco abuse	Migraine
Depression	Osteoporosis
Diabetes/diabetic neuropathy	Peripheral artery disease
Epilepsy	Polycystic ovarian disease
Acid reflux disorder	Stroke

Note: ^aSingle and multiple chronic disorders listed separately.

Written narrative reflections on treatment of chronic illnesses

Previous research showed that reflecting in writing about patient care improves physicians’ self-awareness while providing them with an important emotional outlet (Kumagai 2008; Levine et al. 2008). After trainees were provided with examples of such narratives, they were tasked with writing their own narratives on the treatment of chronic illnesses. Inclusion of their narrative writings in a Readings and Reflections folder was required (Figure 1). The narratives, which were often several paragraphs long, expressed the trainees’ personal reactions to specific chronic illnesses and the feelings that the illnesses and their interventions evoked in them.

Chronic illness portfolio

Maintaining a portfolio of learning artifacts has become an important part of the training of many physicians. The medical education literature contains reports of differences in opinion regarding the uses and consequences of portfolios when used primarily as tools to evaluate the competence and recertification (Nagler et al. 2009). However, two review studies of portfolios in undergraduate and post graduate medical education found some evidence that their use can promote feedback and encourage learners to take responsibility for their own learning (Buckley et al. 2009; Tochel et al. 2009).

In the CINED program, the electronic chronic illness portfolio was used as a tool to encourage our faculty to provide feedback on the four chronic illness educational components and for trainees to take responsibility for documenting their learning about the chronic illnesses. Thus, the trainees were offered annual portfolio development and evaluation workshops that prepared them to build their portfolios with evidence of the four CINED components. During the training period, trainees downloaded documents into the appropriate folders on their flash drives (Figure 1). At the end of the program, they gave their portfolio to CINED faculty who reviewed the portfolios and provided individual formative feedback regarding their content. The CINED faculty also designed a summative 5-step CINED portfolio instrument that they used to rate each trainee's effectiveness in documenting CINED activities (Table 2).

Table 2.  Chronic illness needs educated doctors – portfolio evaluation

We obtained two peer evaluations and one faculty evaluation of each portfolio. Peer and faculty evaluations took place during workshops at which trainees had access to their own portfolios and to those of two randomly selected peers whom they were assigned to evaluate. We served as workshop leaders, instructing the trainees and faculty how to score the portfolios on the Likert scale. Following the workshop, we gave the trainees the opportunity to improve their portfolios before the final ratings. We gave certificates of excellence to all portfolios that exceeded expectations in each of the five portfolio-ranking categories (Table 2).

Summary of the results of OSCE-based analysis of CINED

Since the 1970s, the OSCE has served as a method of observing trainees in multi-station settings that test specific clinical skills (Hodges B, 2003). An objective OSCE was developed by our group faculty to determine whether the CINED program affected the trainees’ communication skills, differential diagnosis, ethics/professionalism, and physical examination skills. We used cases at our institution, such as patient checklists and background information that contained items relevant to each patient's medical history, current complaints, and signs and symptoms of chronic illness. All case materials and standardized patients were available from the Standardized Patient Program at The University of Texas Medical School at Houston. Chronic illness cases used in the OSCE depicted variations of five chronic illnesses commonly seen by family physicians. Specifically, the CINED faculty selected cases representing depression, hypertension, diabetes, shortness of breath, and chronic tobacco use for presentation to the trainees. The CINED program faculty added SF-36 mental and physical component scores as clinical background information.

Before initiating the OSCEs, the trainees were briefed on the OSCE process. Specifically, they learned the signals used to start and conclude each encounter with a standardized patient. The briefings also familiarized the trainees with the dual roles of the standardized patients in presenting the cases to them while observing and evaluating trainees’ clinical skills. Also, trainees were told that CINED faculty would observe the OSCEs from a central observation room.

During each OSCE, the trainee was given the patient's background, medical history, and SF-36 mental and physical health component scores. Following each of the five encounters, the patient rated the trainee on whether or not he or she obtained information included in the checklist of appropriate encounter items for the specific patient case. These items, which varied in number from 31 to 47, were included on checklists of the following clinical skill categories: communications, differential diagnosis, history-taking, ethics/professionalism, and physical examination skills. All of the OSCE scores were recorded as the percentage of items that the standardized patients rated as complete at each station. The summary “scores” rated the trainees’ average performance across all of the patient cases.

All of the methods described above are consistent with Bandura's research indicating that self-efficacy (i.e., belief in one's ability to achieve his or her desired goals) is the result of disciplined self-monitoring and self-control (Bandura 2004). Following the suggestion of Koo & Fischbach (2008), the CINED faculty promoted self-efficacy among our trainees by keeping them informed about their accomplishments in fulfilling all CINED requirements. We also provided our trainees with relevant feedback about SF-36 measurements. In addition, we gave them specific feedback and ample time to improve their HRQOL measurement, communication, narrative, and presentation skills. The chronic illness portfolios that trainees submitted at the end of the CINED program confirmed that they had applied the faculty's feedback and used examples from CINED training sessions to produce their own quality didactic presentations and written narratives.

Statistical analysis

Student-t tests were used to test the difference between mean values for continuous variables. Correlations were produced to test the degree to which the peer and faculty formative evaluations of the trainees’ portfolio were in agreement. The p-values less than 0.05 were considered as statistically significant. All statistical analyses were performed using SAS (version 9.1.2).

Results

Measurement of HRQOL

We assessed the degree to which trainees learned to measure HRQOL in terms of the number of SF-36 indexes that the trainees administered, scored, and reviewed before sending the scores to us. The 47 trainees administered the SF-36 to 414 patients. The number of patients to whom the trainees administered the SF-36, ranged from 2 to 46, with 18 trainees (38%) administering it to more than 10 patients. We received 30 patient follow-up surveys on SF-36. Our discussions with trainees revealed that those who adopted the program enthusiastically set high administration standards for themselves. Others regarded themselves as “too busy” or “forgot” to administer the SF-36 on a regular basis.

Didactic sessions

In year 2 of the CINED program, the trainees gave 17 PowerPoint-based presentations to trainees and faculty and included the presentations in their chronic illness portfolios; in year 3, the number of presentations increased to 32. Trainees who requested the opportunity to demonstrate an additional best effort gave two additional presentations. Our faculty's review of the presentations showed that they uniformly met departmental program and CINED program standards. Specifically, the presentations were clear, and the information in them was judged by CINED faculty to be accurate and relevant to family medicine physicians. According to the five-point Likert scale used in the department's grand rounds, all of the presentations were scored greater than four. The sole criticisms of the presentations levied by the faculty and peers were related to issues resulting from lack of experience in presenting the educational material rather than insufficient content. Presentations included background information on the patient chronic illness, relevant lectures, readings relevant to understanding the problem, and the interventions performed. Table 1 lists the wide variety of chronic illness topics presented in the didactic sessions. In addition, the trainees documented that they had given presentations of selected chronic illness topics, such as home visits to chronically ill patients, in didactic sessions sponsored by other departments.

Narrative reflections

An iterative qualitative content analysis process described and validated by Quinn (1980) was used to evaluate narratives. In addition to gaining an understanding of narrative categories, we were interested in learning how the trainees would use the brief outline that we placed in the Reflections and Presentations folder of the portfolio (Figure 1). The authors read and reread the trainees 93 narrative reflections. After categorizing each reflection independently, we verified the categories by reviewing the list together. Then, we repeatedly reduced the list of categories until we were satisfied that the remaining categories included all reflections. We assigned a name to each category and quoted written reflections that we felt best summarized the categories. Next, we selected the narrative reflection that appears below, one which describes a complex patient with chronic co-morbidities, as the one most representative of the content analysis. We found that the reflections on the representative patient incorporated, but did not duplicate, the outline that we provided in the Presentations and Reflections folder.

Past medical history

The patient was a 46-year-old woman with a history of migraines and seizures over many years. Her last seizure occurred many years before this visit. The patient was on Depakote for prophylaxis. Physicians managed her migraines with ibuprofen and acetaminophen (Tylenol), which produced little relief. The patient previously underwent extensive work-up, and all results of physicals and labs were negative. The patient had a significant family history of migraines and a history of smoking.

Present illness

The patient's migraines had recently increased in frequency, and she was under the impression that she may have been having seizures while sleeping. Intensive questioning revealed that the patient was feeling guilty for being a single mother, as she felt that she was not providing her children with the kind of life she had enjoyed when she was growing up. She was tense, tearful, and obviously depressed.

Assessment/diagnosis

We diagnosed her as having migraines, a history of seizures, and depression.

SF-36

The patient's SF-36 physical component score was 39, and her mental component score was 29.

Interpretation of the patient's SF-36 scores

Both scores were far below the average of 50. This patient had a very poor impression of her health. Her mental component score was in keeping with her diagnosis of depression.

Learning points

(1) Patients’ physical and mental health sometimes cannot be separated. I learned from this narrative a holistic approach to health care is likely to succeed, especially when more than one morbidity exists. In a stepwise approach to solving health problems, the issue of smoking and/or alcohol cessation is not likely to be well handled by a patient who has depression or chronic pain, as he or she is probably self-medicating with those substances.

(2) Always take a patient's perception of health seriously and use [their] perceptions to make patients faithful allies in their own care.

Chronic illness OSCE

Figure 2 shows the formative chronic illness OSCE results in academic years 2007 and 2008. In both academic years, trainees had the highest scores for obtaining the correct differential diagnoses demonstrating the ability to communicate well with the patients, and for adhering to ethical standards of the OSCE (e.g., draping the patient, maintaining eye contact). Discussions with faculty and trainees led us to believe that the trainees were effective in these three areas because they practiced these skills on an almost daily basis on a high volume of CI clinic patients. Additionally, they stated that consistent communications training by the behavioral faculty alerted them to effective communications and ethical behaviors. Taking the history, scores demonstrated the trainees’ relative completeness. However, these scores may have remained almost static over the 2 years because history-taking skills were not reinforced specifically by the CINED faculty. As shown in Figure 2, the scores for professionalism and ethics changed greatly over the 2 years. The aspect of care in which the trainees needed the most improvement was physical examination skills, which were not taught in CINED workshops and didactic sessions. The literature shows that teaching and feedback events on physical examination are infrequent after medical training. Indeed, skills such as cardiac examination tend to decrease after medical school training (Vakanovic-Criley et al. 2006). Faculty either do not offer feedback on physical examination or offer it sporadically.

Figure 2. Mean chronic illness OSCE scores for CINED program trainees.

Summary chronic illness portfolios

In academic years 2007 and 2008, our trainees submitted 11 and 23 portfolios, respectively, as evidence of their professional development in caring for patients with chronic illnesses. Thus, we reviewed the portfolios of 72% of the trainees who participated in the final 2 years of the CINED program. The correlation between the faculty and peer reviews of the portfolios was 0.47 (p < 0.05), indicating that there was moderate agreement and that trainees as well as faculty can provide feedback on portfolios.

We were concerned that so few portfolios were submitted in 2007 and that none of those submitted met the criteria for a certificate of excellence. During our discussions with the trainees, they expressed their lack of experience with portfolios, their lack of confidence in producing a high quality portfolio, and the fact that submitting portfolios did not affect their graduation. Thus, we added two new workshop sessions that provided a rationale for maintaining a portfolio as a way to keep track of their personal ongoing professional development. We also gave specific instruction on necessary methods for achieving an excellent portfolio. In 2008, 13 portfolios met our criteria for a certificate of excellence and the remainder was rated satisfactory. We placed a copy of the certificate of excellence and a summary of the evaluations in each trainee's permanent file.

Discussion and conclusions

Results suggest that we were effective in designing, administering, and evaluating an innovative chronic illness training program that encouraged the trainees to focus simultaneously on their patients’ chronic illnesses and on their own professional development. We were pleased by the accuracy of the trainees’ diagnoses and their communications in the OSCE. The OSCE's measures for ethics and professionalism need to be expanded beyond two items so that accurate assessments of accuracy in these two clinical areas can be made. We were disappointed by the trainees’ low accuracy in physical examination observed in the OSCE. The medical education literature reveals that specific training courses can lead to improvement in physical examination scores. However, the CINED curriculum did not emphasize physical examination. Even repeated evaluations do not necessarily lead to improved physical examination scores among trainees who encounter some of the same patients in successive OSCE's (Swygert et al. 2010).

Our trainees learned the importance of ascertaining their patients’ perceptions of the chronic illnesses by using an HRQOL instrument. They also demonstrated effectiveness in making differential diagnoses regarding chronic illnesses and in communicating effectively with their chronically ill patients. We believe that the variety of teaching, feedback, and evaluation techniques used in the CINED program provide an outcomes-oriented, comprehensive approach to training physicians how to manage chronic illnesses. Using information described herein, medical teachers may be able to adapt to their own institutional settings all or portions of the CINED program's four components. It would be useful to test the effectiveness of CINED activities across institutions.

Our experiences with the CINED program suggest that an HRQOL instrument such as the SF-36 can jump-start trainees’ self-directed learning about and development of processes for managing chronic illnesses. Aspects of all four components of CINED can support trainees with achieving professional development as graduate physicians. We learned from the narratives that the CINED trainee who administered the SF-36 11 times used a prompting system for herself as a reminder to make telephone contacts with her patients. In general, trainees who pursued independent learning and self-monitoring most vigorously, and who used the guidelines that we offered, succeeded in obtaining certificates of excellence. These self-regulated learners consistently provided the documentation of their professional reading, narratives, presentations, and conferences in their chronic illness portfolios. The entire contents of their electronic portfolios offered evidence of their most recent chronic illness learning and provided a baseline for documenting their ongoing learning (Levine et al. 2008). In addition, the CINED training encouraged excellence in the accuracy of the trainees to make the correct physical diagnosis and communicate effectively with chronically ill patients.

Next steps

We make the following four suggestions for chronic illness training and research based upon our experiences with CINED.

1. Expand the CINED curriculum to other comparable institutions that offer the possibility of a control or comparator group. This will make it possible for some trainees to receive the curriculum while others do not. We believe that all of the four CINED components described herein are likely to be adapted entirely or in part to other primary care programs.

2. Encourage those responsible for medical records to include the SF-36 scores as useful measure in their patients’ medical records.

3. Observe the CINED trainees in their post-training careers to determine whether they maintained the skills taught in the CINED program.

4. Serve as a spokesperson for the CINED methods and learning materials.

Declaration of interest: This program was supported in part by Health Resources and Services Administration (HRSA) grant D58HP05146 in the Department of Family and Community Medicine of the University of Texas Health Science Center Medical School at Houston. We thank Diana R. Brownfield, Senior Education Coordinator at The University of Texas Health Science Center at Houston, for her assistance with document preparation and Rebecca Bryson for coordinating CINE program activities.