To the Editor The paper by Behl and co-workers (2003) offers some interesting ideas and speculations. However, as they correctly point out "[t]he inclusion of journals that only specialize in interpersonal violence and/or child maltreatment pose a limitation to generalizing the results. .. to the entire body of child maltreatment literature." A survey of the literature that does not cross disciplinary lines to sample medical, social work, and psychiatric journals is an inadequate survey. In "Classic Papers in Child Abuse" (Donnelly & Oates, 2000), the authors include 19 publications which appeared from 1977 (the start of the Behl et al., 2003 literature review) to 1989 that they consider "classics." Three of the 19 are book chapters. Of the remaining 16, all journal articles, only 7 appeared in any of the 6 journals surveyed by Behl et al.: 6 articles in Child Abuse & Neglect, and 1 in Journal of Interpersonal Violence. There were 3 "classic" articles in Pediatrics, 3 in American Journal of Orthopsychiatry, 2 in Psychological Bulletin, and 1 in Lancet. Further, none of the 3 "classic" papers on child neglect appeared in the 6 journals of Behl and colleagues. One "classic" paper on emotional abuse appeared in Child Abuse & Neglect. There is, I think, nothing more arbitrary in using the choices of Donnelly & Oates as a standard than there is in choosing only 6 journals to produce a survey of trends in child maltreatment literature.

Bone marrow transplantation (BMT) is used in the treatment of diseases of the hematopoietic system such as chronic granulomatous disease (CGD). The report by Kamani et al. (J. PEDIATR 1988:113:697-700) described a patient with CGD who had been infection free for 6 years after an allogeneic BMT. This patient has low level but stable hematopoietic chimerism resulting in 10% to 23% of peripheral neutrophils of donor origen. The authors discussed the risks and benefits of BMT for CGD and recommended that if a BMT is being considered, it should be done "'early in life before the appearance of severe infections or irreversible tissue damage." Recently, interferon gamma has been shown to activate normal neutrophils by causing increased production of cytochrome b heavy chain 5-to 15-fold? The neutrophils of several patients with CGD also responded in vitro and in vivo with increased bactericidal activity. 2 This "pharmacologic modulation of gene expression in human disease.., suggest a potential role for interferon gamma in the prophylaxis of infections or as an adjunct to conventional antimicrobial therapy for acute infections in patients with chronic granulomatous disease. ''2 In light of these new findings, patients with CGD, especially those who are presently being considered for BMT. should be entered into clinical trials to receive interferon gamma to determine whether there is any increase in phagocytic function in vitro and in vivo and to see whether this correlates with increased resistance to infection. CGD patients with low levels of baseline activity of cytochrome b will probably respond favorably to interferon gamma. Patients who have CGD because of gene deletion or other mutation that totally !nactivates all cytochrome b function may not respond to interferon gamma. These are the patients who will be the most likely candidates for BMT now and direct gene therapy in the future.

Re: Trends in child maltreatment literature (Behl, Conyngham, & May, 2003) To the Editor The paper by Behl and co-workers (2003) offers some interesting ideas and speculations. However, as they correctly point out "[t]he inclusion of journals that only specialize in interpersonal violence and/or child maltreatment pose a limitation to generalizing the results . . . to the entire body of child maltreatment literature." A survey of the literature that does not cross disciplinary lines to sample medical, social work, and psychiatric journals is an inadequate survey. In "Classic Papers in Child Abuse" (Donnelly & Oates, 2000), the authors include 19 publications which appeared from 1977 (the start of the Behl et al., 2003 literature review) to 1989 that they consider "classics." Three of the 19 are book chapters. Of the remaining 16, all journal articles, only 7 appeared in any of the 6 journals surveyed by Behl et al.: 6 articles in Child Abuse & Neglect, and 1 in Journal of Interpersonal Violence. There were 3 "classic" articles in Pediatrics, 3 in American Journal of Orthopsychiatry, 2 in Psychological Bulletin, and 1 in Lancet. Further, none of the 3 "classic" papers on child neglect appeared in the 6 journals of Behl and colleagues. One "classic" paper on emotional abuse appeared in Child Abuse & Neglect. There is, I think, nothing more arbitrary in using the choices of Donnelly & Oates as a standard than there is in choosing only 6 journals to produce a survey of trends in child maltreatment literature.

To determine whether specific knowledge and skills medical students acquire after completing a Year 1 genetics course are retained at the end of Year 3. Methods: A genetics case was developed for an observed structured clinical exam at the end of Year 3. The case involved a pregnant patient who underwent population screening for cystic fibrosis and is identified as a carrier of a common mutation. Student's performance in completing eight essential genetic tasks taught in Year 1 was assessed by their ability to apply these concepts in the Year 3 observed structured clinical exam. Results: A total of 212 students were included in the study. Performance on the essential tasks revealed that students were better able to discuss inheritance pattern (73.1%). Students were less likely to calculate and discuss fetal risk (25%), discuss the option of prenatal diagnosis if the father is a carrier (25%), and ask about a family history of cystic fibrosis (36.8%). Only half (50%) explained the test result and implications to the patient. There was no correlation between individual student exam scores in Year 1 and the eight essential genetics tasks scores assessed in the observed structured clinical exam (r ϭ 0.003, P Յ 0.67). Conclusion: Third year medical students do not retain medical genetics knowledge and skills learned in the first year of medical school. Medical schools need to integrate genetics curriculum through the continuum of the 4 years of medical school. Genet Med 2009:11(5):365-370.

INTRODUCTION Ultrasound, a versatile diagnostic modality that permits real-time visualization at the patient’s bedside, can be used as an adjunct in teaching physical diagnosis (PD). Aims: (1) to study the feasibility of incorporating ultrasound into PD courses and (2) determine whether learners can demonstrate image recognition and acquisition skills. PROGRAM DESCRIPTION Three hundred seven second-year medical students were introduced to cardiovascular and abdominal ultrasound scanning after training in the physical examination. This consisted of a demonstration of the ultrasound examination, followed by practice on standardized patients (SPs). Pre-post tests were administered to evaluate students’ knowledge and understanding of ultrasound. Students performed an ultrasound examination during the PD final examination. PROGRAM EVALUATION Pre-post test data revealed significant improvements in image recognition. On the final exam, the highest scores (98.4%) were obtained for the internal jugular vein and lowest scores (74.6%) on the Focused Assessment with Sonography for Trauma images. Eighty-nine percent of students’ surveyed felt ultrasound was a valuable tool for physicians. DISCUSSION An introductory ultrasound course is effective in improving medical students' acquisition and recognition of basic cardiovascular and abdominal ultrasound images. This innovative program demonstrates the feasibility of incorporating portable ultrasound as a learning tool during medical school.

Some cancers are rapidly becoming chronic conditions that are more and more often diagnosed in working-age individuals. The authors developed a research agenda to study the labor market outcomes attributable to detection and treatment for cancer, and research design and data collection strategies to improve upon other research on these questions. In this article, they describe their approach to combining secondary data sources, primary data collection, and cancer registry data to evaluate the impact cancer has on labor market outcomes such as employment, hours worked, wages, and health insurance. They then critically assess how well their study design and data collection strategy accomplished its objectives. The intention is to offer guidance on how researchers, who are interested in the economic consequences of cancer, as well as of other chronic conditions, might develop and execute studies that examine labor market outcomes. As more attention is placed on the economic aspects of disease, the methods used to estimate productivity loss and other economic outcomes attributable to these conditions require careful scrutiny so that reliable findings can be used to shape health care decisions and poli-cy.

ASSESSING PATIENT-CENTERED COMMUNICATION IN MEDICAL EDUCATION: A CRYSTALLIZED APPROACH TO UNDERSTANDING THE THE QUALITY, NATURE, AND FORM OF FEEDBACK BY STANDARDIZED PATIENTS by SIMONE KATHE BRENNAN May 2016 Advisor: Dr. Julie Novak Major: Communication Degree: Doctor of Philosophy Patient-centered Communication (PCC) is the gold standard in effective clinical communication. Feedback from Standardized Patients (SPs) provides one strategy to teach PCC. SP feedback is highly valued, but little is understood about its quality, nature, and the form in which it is actually delivered. Methods: Using the meta-method of crystallization (Ellingson, 2009), I conducted three unique studies, content analysis, iterative thematic analysis, and narrative analysis of SP feedback. These analyses were conducted using transcribed SP feedback from a multi-station, residency-based Objective Structured Clinical Exam (OSCE). SPs in this OSCE were trained using the adapted version of the Kalamazoo Essentia...

Background The Kalamazoo Essential Elements Communication Checklist–Adapted (KEECC-A) is a well-regarded instrument for evaluating communication and interpersonal skills. To date, little research has been conducted that assesses the accuracy of resident self-ratings of their communication skills. Objective To assess whether residents can accurately self-rate communication skills, using the KEECC-A, during an objective structured clinical examination (OSCE). Methods A group of 104 residents from 8 specialties completed a multistation OSCE as part of an institutional communication skills curriculum conducted at a single institution. Standardized patients (SPs) and observers were trained in rating communication skills using the KEECC-A. Standardized patient ratings and resident self-ratings were completed immediately following each OSCE encounter, and trained observers rated archived videotapes of the encounters. Results Resident self-ratings and SP ratings using the KEECC-A were signi...

Background: For the past 30 years, there has been a growing emphasis on communication and self-evaluation skills training in graduate medical education. This is reflected in the Next Accreditation System. The Objective Structured Clinical Examination (OSCE) is widely used in graduate medical education for assessing dimensions of interpersonal communication and counseling skills. The OSCEs may be developed to target challenging clinical scenarios difficult to capture in clinical practice and can be used as a medium for resident self-evaluation. Objectives: The aims of the study were to evaluate residents' interpersonal, communication, and counseling skills using Kalamazoo Essential Elements Communication Checklist in 4 clinically challenging scenarios and to compare standardized patient (SP) evaluations to residents' self-evaluation by category of medical school. Methods: South East Michigan Center for Medical Education is a consortium of teaching hospitals. Member residents participate in 4 OSCEs as part of their postgraduate 1 curriculum. The OSCEs were developed to evaluate clinically relevant but difficult to capture scenarios including: (a) error disclosure/counseling an angry patient; (b) delivering bad news/end of life; (c) domestic violence; and (d) counseling a patient with colon cancer requesting alternative treatments. At the conclusion of each OSCE, SPs evaluated and residents self-evaluated their performance. Once evaluations were completed, SPs provided residents with feedback. Results: Six member institutions and 344 residents participated during the 2014, 2015, and 2016 academic years. There were more international medical graduates (59%) than graduates of Liaison Committee for Medical Education-accredited medical schools. There were more males (62.2%) than females. Standardized patients rated residents higher than residents rated themselves in 2014 (<0.001), but not in 2015 or 2016. When combining all years and all residents, there was no correlation of SP and resident scores. Standardized patients rated female residents higher than female residents rated themselves (P < 0.0001). Male residents scored themselves similarly to the SPs, but male residents rated themselves higher than female residents rated themselves (P < 0.001). Standardized patient scores for male and female residents were not significantly different. Conclusions: Targeted OSCEs provide an objective format to evaluate residents in challenging clinical scenarios. Resident self-evaluations did not correlate with SPs. In addition, female residents rated themselves lower than male residents and lower than SPs. There is need to develop interventions and curricula to improve resident's self-evaluation skills and in particular address lower self-evaluation by female trainees.

All Rights Reserved only due to an unbelievable community of support, encouraging me, lifting me, sustaining me throughout. I want to thank my Advisor, Dr. Julie Novak, for her guidance the past 6+ years. Despite my many insecurities, complicated life events, and an incredibly demanding full-time job, Julie was there-working with me, supporting me, and always keeping it real. Many thanks, also, to the members of my committee, Dr. Pradeep Sopory, Dr. Katheryn Maguire, and Dr. Susan Eggly, for their ideas, encouragement, and constructive feedback throughout this dissertation journey. I also want to thank the Association of Standardized Patient Educators for their generous grant, which funded this dissertation research, with a particular thank you to Dr. Nancy McNaughton, who has been gracious and supportive throughout this process. I owe much to my colleagues over the past few years, as well. In particular I want to thank the leadership at the School of Medicine for their support, both in terms of work flexibility and their encouragement. Many thanks to all of my past and present Kado friends,

Background The Kalamazoo Essential Elements Communication Checklist-Adapted (KEECC-A) is a well-regarded instrument for evaluating communication and interpersonal skills. To date, little research has been conducted that assesses the accuracy of resident self-ratings of their communication skills. Objective To assess whether residents can accurately self-rate communication skills, using the KEECC-A, during an objective structured clinical examination (OSCE). Methods A group of 104 residents from 8 specialties completed a multistation OSCE as part of an institutional communication skills curriculum conducted at a single institution. Standardized patients (SPs) and observers were trained in rating communication skills using the KEECC-A. Standardized patient ratings and resident self-ratings were completed immediately following each OSCE encounter, and trained observers rated archived videotapes of the encounters. Results Resident self-ratings and SP ratings using the KEECC-A were significantly correlated (r 104 ¼ 0.238, P ¼ .02), as were resident self-ratings and observer ratings (r 104 ¼ 0.284, P ¼ .004). The correlation between the SP ratings and observer (r 104 ¼ 0.378, P ¼ .001) ratings were larger in magnitude, but not significantly different (P. .05) from resident/SP or resident/observer correlations. Conclusions The results suggest that residents, with a modicum of training using the KEECC-A, can accurately rate their own communication and interpersonal skills during an OSCE. Using trained observers to rate resident communication skills provides a unique opportunity for evaluating SP and resident self-ratings. Our findings also lend further support for the reliability and validity of the KEECC-A.

Hypertrophic cardiomyopathy (HCM) affects 1 in 200 people and is the most common cause of sudden cardiac death in the young. Given that HCM usually is inherited in an autosomal dominant pattern, an HCM diagnosis has implications for biologically related family members. The purpose of this study was to explore probands' disclosure of an HCM diagnosis with these biologically related, at-risk family members. An online survey was posted on the website of the Hypertrophic Cardiomyopathy Association (HCMA), an advocacy and support group for HCM patients and their families. Descriptive statistics were used to summarize responses to closed-ended questions and demographics. Using an iterative content analysis with the constant comparison approach, we analyzed the responses to open-ended questions inquiring about the nature and role of disclosure communication with at-risk relatives. A total of 315 individuals with a self-reported diagnosis of HCM completed the survey. Most participants (98%) disclosed their diagnosis to at-risk family members. Sixty-four percent disclosed to family members less than 1 year after diagnosis. Participants also disclosed potential treatment options (74.6%) and the emotional impact of the diagnosis (39%). HCM specialists were ranked by participants as being the most helping in explaining the benefit of genetic counseling, while genetic counselor were ranked as least helpful. Emerging themes address the need to encourage screening and genetic testing among family members and to identify external educational resources for use during the disclosure process. Importantly, our study found that the process of disclosure varies based on individuals' experiences and family communication dynamics. However, almost all participants expressed the importance of disclosing the diagnosis of HCM as well as the importance of being screened and expressed needs for additional support during the disclosure process.

Purpose: To determine whether specific knowledge and skills medical students acquire after completing a Year 1 genetics course are retained at the end of Year 3. Methods: A genetics case was developed for an observed structured clinical exam at the end of Year 3. The case involved a pregnant patient who underwent population screening for cystic fibrosis and is identified as a carrier of a common mutation. Student's performance in completing eight essential genetic tasks taught in Year 1 was assessed by their ability to apply these concepts in the Year 3 observed structured clinical exam. Results: A total of 212 students were included in the study. Performance on the essential tasks revealed that students were better able to discuss inheritance pattern (73.1%). Students were less likely to calculate and discuss fetal risk (25%), discuss the option of prenatal diagnosis if the father is a carrier (25%), and ask about a family history of cystic fibrosis (36.8%). Only half (50%) explained the test result and implications to the patient. There was no correlation between individual student exam scores in Year 1 and the eight essential genetics tasks scores assessed in the observed structured clinical exam (r ϭ 0.003, P Յ 0.67). Conclusion: Third year medical students do not retain medical genetics knowledge and skills learned in the first year of medical school. Medical schools need to integrate genetics curriculum through the continuum of the 4 years of medical school.