Third year internal medicine clerkship students at Michigan State University (MSU) College of Human Medicine (CHM) were offered an opportunity to participate in the study. The pilot data presented in this report were based on students in the second and third rotation of the clerkship during the 2003–2004 academic year.
The family practice clerkship at CHM implemented an educational module to enhance skills in common preventive services and teach students how to inform and involve patients concerning those services. Students are trained to use a variation of a model developed by Braddock and colleagues [2
]. Braddock's model includes seven elements of informed decision making:
1. Discussion of the patient's role in decision making
2. Discussion of the clinical issue or nature of the decision
3. Discussion of the alternatives
4. Discussion of the pros and cons of the alternatives
5. Discussion of uncertainties associated with the decision
6. Assessment of the patient's understanding
7. Exploration of patient preference
Specific decisions are also categorized into "basic", "intermediate", and "complex".
PDM is presented and modelled by faculty, discussed in small groups, and practiced using web-based case simulations. Students must pass an evaluative SPE on shared decision-making and preventive services prior to completion of the clerkship.
During the third-year internal medicine clerkship, students participate in an all day skills workshop conducted during the second week of the eight-week clerkship. The SPE station was one of five small group sessions included in the workshop. Students rotate through the small group sessions and three whole group sessions over the course of the day. The SPE station was intended to provide feedback, and it was made clear to the students that their performance would not impact on their clerkship grade.
The SPE station is structured as an office appointment for a man in his early twenties with a first time seizure. Before meeting the SP, students are given a "patient file" providing the results of a history and physical examination. To ensure adequate knowledge on the part of the student, they are provided with a fact sheet about seizures. Students are given approximately five minutes to review the material. Each student then spent up to 20 minutes discussing treatment options and the implications of the seizure with the SP while being observed by a faculty member. During the last five minutes of the session, the faculty member along with the SP provided verbal feedback to the student. The faculty member also completed a rating form based on key skills taught in the family practice module and other desirable case-specific behaviors. The rating items are listed in Table . Performance was rated as "poor/not attempted," "adequate," or "excellent." There were three replications of the case that were necessary to allow all the students in the workshop to complete the station. The authors as well as other faculty rated the students. The faculty raters discussed the rating criteria, however, no formal training was given in how to rate the students. It was felt that the rating criteria were clear and no additional training was needed.
Rating scale used by faculty in evaluating the students
At CHM, the three required primary care clerkships (pediatrics, family practice and internal medicine) are taken during the first three eight-week rotations of the third year of medical school. This rotational structure forms a natural experimental design. The order in which students rotate through the clerkships is arbitrary, and we believe, unlikely to bias the results of this study in any systematic way. For practical purposes, we believe it approximates random assignment.
During the second rotation of the academic year a portion of the students taking the internal medicine clerkship have completed the family practice clerkship and the PDM module during the first rotation, while the rest completed the pediatrics clerkship. During the third rotation, all students have completed the family practice clerkship; however, a portion completed it during the first rotation, approximately 12 weeks prior to the SPE, while the others completed it during the second rotation, or approximately four weeks prior to the exercise.
The rotational structure forms the study design shown in Table . The contrast in performance between students in cells 2 and 3 of the design (the students in the second rotation of the internal medicine clerkship) forms a pseudo-randomized trial of the impact of completing the family practice clerkship including the PDM training module as compared with completing the pediatrics clerkship without the PDM module on the students' use of PDM techniques in counseling a patient in the SPE. The contrast between cells 4 and 5 in the design (students completing the third rotation of the internal medicine clerkship) forms a parallel design to that between cells 2 and 3. The comparison, however, assesses the impact of completing the family practice clerkship and the PDM module approximately four weeks versus approximately 12 weeks prior to the SPE. Since the faculty members rating the students did not know a particular student's rotation schedule, and the students were not informed at the time of the SPE of the specifics of the study, the design is also essentially double-blinded.
Study design formed by the clerkship rotational schedule*
Two scales were formed from the individual items on the rating sheet. The first was a total score or sum of all 11 items. A second "PDM" score was a sum of the items that specifically reflected the elements of the Braddock model; items 1–4, 6 and 9 from Table .
The students' performance was rated as "poor/not attempted," "adequate," or "excellent" on a three point scale with "excellent" rated as a "3". Given the small sample size of this pilot study, we chose to test for statistically significant differences between the groups using non-parametric tests. Both the Kruskal-Wallis test for difference in ranks and the "median test" for differences in medians were used to test for differences among the four groups. When differences were found, a post-hoc analysis was performed. The tests were repeated on subsets of the data to test for differences among pairs of the groups that addressed the key research questions, (cell 2 versus cell 3 and cell 4 versus cell 5 of Table ) as suggested by Conover [10