Molly Cooke | University of California, San Francisco (original) (raw)
Papers by Molly Cooke
Journal of General Internal Medicine, Mar 1, 2011
Acad Med, 2001
The Interdisciplinary Generalist Curriculum (IGC) Project created curricular changes at the parti... more The Interdisciplinary Generalist Curriculum (IGC) Project created curricular changes at the participating schools with very little direct financial support. A reconsideration of the process of this national effort reveals many intangible elements that were as critical to the project's successes as were the direct dollars. Those factors included careful attention to the criteria for school selection, specific project requirements that allowed institutional flexibility in project evolution, national assistance in program implementation, early and ongoing national recognition for project schools, and a highly organized, involved, and goal-oriented national organization. This national initiative provides a successful model for future funding of projects in this era of dwindling financial support for medical education innovation.
Http Dx Doi Org 10 1089 Jpm 2000 3 7, Apr 19, 2005
Teaching medical students to respond to needs of the dying represents an important challenge for ... more Teaching medical students to respond to needs of the dying represents an important challenge for medical educators. This article describes the goals and objectives that should be identified before medical schools can meet this challenge, as well as strategies that, when implemented, will provide students with the necessary knowledge, skills, and attitudes to meet the needs of the dying patients. The goals and objectives were identified through a modified group consensus process developed during Choice In Dying's 5-year project "Integrating Education on Care of the Dying into Medical Schools." The authors have diverse experiences and backgrounds and are actively involved in death and dying teaching at 11 medical schools. They conclude that after accepting the goals and objectives, key medical school faculty can work cooperatively to develop strategies to integrate them into the school's curriculum. Without first establishing a set of goals and objectives and developing evaluation methods, medical schools could miss their mark in fostering the student's ability to care for the dying.
QRB. Quality review bulletin
Western Journal of Medicine
Annals of internal medicine
Voluntary screening for human immunodeficiency virus (HIV) infection may help prevent the spread ... more Voluntary screening for human immunodeficiency virus (HIV) infection may help prevent the spread of the HIV epidemic if persons who test positive alter behaviors that may transmit infection. Protecting persons from unknowingly being exposed to HIV infection must be balanced against respecting the autonomy of individuals being screened. Seropositive patients may feel a stigma and be subjected to discrimination if confidentiality of test results is breached. In patients without high-risk behaviors, the positive predictive value of HIV testing may be substantially increased if tests are done in reference laboratories and if further confirmatory tests are run on a second blood specimen. For persons with high-risk behaviors, HIV testing can be recommended to those who want to reduce uncertainty about their HIV status or whose medical care would change if they were seropositive. Health care workers can maximize benefits of screening and minimize harm by educating and counseling patients before HIV testing, discussing the confidentiality of HIV test results, urging patients to disclose positive test results to sex partners, and advising patients on how to reduce high-risk behaviors.
The authors describe the first four years (1995-1998) in which the University of California, San ... more The authors describe the first four years (1995-1998) in which the University of California, San Francisco School of Medicine operated an evaluation system to monitor students' professional behaviors longitudinally through their clinical rotations. The goals of this system are to help "turn around" students found to have behaved unprofessionally, to demonstrate the priority placed by the school on the attainment of professional behavior, and to give the school "muscle" to deal with issues of professionalism. A student whose professional skills are rated less than solid at the end of the clerkship receives a "physicianship report" of unprofessional behavior. If the student receives such a report from two or more clerkships, he or she is placed on academic probation that can lead to dismissal even if passing grades are attained in all rotations. Counseling services and mentoring by faculty are provided to such students to improve their professional behaviors. From 1995 to 1998, 29 reports of unprofessional behavior on the part of 24 students were submitted to the dean's office; five students received two reports. The clerkship that submitted the most reports was obstetrics-gynecology. The most common complaint for the five students who received two reports was a poor relationship with the health care team. Four of these students had their difficulties cited in their dean's letters and went on to residency; the fifth voluntarily withdrew from medical school. The authors describe the students' and faculty members' responses to the system, discus lessons learned, difficulties, and continuing issues, review future plans (e.g., the system will be expanded to the first two years of medical school), and reflect on dealing with issues of professionalism in medical school and the importance of a longitudinal (i.e., not course-by-course) approach to monitoring students' behaviors. The authors plan to compare the long-range performances of students identified by the evaluation system with those of their classmates.
Western Journal of Medicine
Ethnicity & disease
To determine whether ethnic and other social factors affect how frequently do-not-resuscitate (DN... more To determine whether ethnic and other social factors affect how frequently do-not-resuscitate (DNR) orders are written, the timing of DNR orders, or patient involvement in the DNR decision. Retrospective cohort. Patients who died in one urban teaching hospital on the medicine, cardiology, or family practice service during 1988 were eligible; 288 were included in the analyses. Chi-square tests and logistic regression were used to examine frequency of DNR orders and patient involvement; analysis of variance and linear regression were used to examine timing of the DNR orders. Non-whites were more likely than whites to have DNR orders (OR 1.76; 95% CI, 1.09-2.84) but timing of the DNR order did not vary significantly by race/ethnicity. Patients who spoke English fluently were more likely to be involved in the DNR decision than those who did not (OR 1.28; 95% CI, 1.01-1.61). Patients with documented human immunodeficiency virus were more likely than uninfected patients to have DNR orders (OR 3.51; 95% CI, 1.36-9.02), to be involved in the decision (OR 10.11; 95% CI, 4.87-21.00); and to have DNR orders written earlier (P = 0.02). Alcoholic patients were more likely than non-alcoholics to have DNR orders (OR 1.17; 95% CI, 1.04-1.33). Ethnic and other social factors do appear to play a role in DNR decisions. It needs to be determined if these differences are due to patient preferences or clinician characteristics.
Academic Medicine
At most medical schools students spend the core clerkship year entirely in clinical settings, geo... more At most medical schools students spend the core clerkship year entirely in clinical settings, geographically dispersed, and assigned to separate teams. Because of the immediacy of experiential learning in the clinical environment, this year is often the highlight of medical school. However, the intensity of the experience and the dispersion of students poses serious challenges to student well being and professional development, and to meeting important educational objectives best taught in the clinical year but difficult to implement in competition with direct patient care. To address these challenges in a way that does not interfere with the clinical experiences, we developed and are implementing three one-week intersessions. These are designated weeks between clerkship rotations when all third-year students are "off rotations" and studying together in an integrative, collaborative and reflective manner. We identified themes for the intersession course from several source...
AIDS Education and Prevention
Physicians can help prevent transmission of HIV by assessing HIV positive patients for risky sexu... more Physicians can help prevent transmission of HIV by assessing HIV positive patients for risky sexual and needle-sharing behaviors, and by providing risk reduction counseling. From 1995 to 1997, we gathered data on the HIV transmission prevention assessment and counseling practices of 44 San Francisco Bay area physicians in face-to-face, semistructured interviews. A refined coding scheme and constant comparative analytic method were used. Although physicians varied in their responses to coded items, two styles of engagement, at the extremes, emerged from the data: "consultant" and "collaborator." Consultants conducted transmission prevention assessment and counseling during initial visits or upon medical cues (e.g., presence of sexually transmitted diseases) and viewed themselves primarily as information sources, whereas collaborators regularly conducted transmission prevention counseling and viewed themselves as actively helping patients reduce transmission risk. ...
Clinical journal of the American Society of Nephrology : CJASN, Jan 7, 2014
The American College of Physicians recently published a guideline on screening for CKD that recom... more The American College of Physicians recently published a guideline on screening for CKD that recommends against screening for CKD in asymptomatic adults without risk factors. The generally accepted criteria for population-based screening for disease state that screening should improve important clinical outcomes while limiting harms for those individuals screened. However, CKD screening does not meet these criteria. There is currently no evidence evaluating or demonstrating benefits for providing early treatment for patients identified via screening who do not have risk factors. On the other hand, harms are associated with the screening and include false-positive results, unnecessary testing and treatment, and disease labeling.
Medical education, 2009
Concerns about the quality of medical student learning experiences during traditional clerkships ... more Concerns about the quality of medical student learning experiences during traditional clerkships have prompted calls to restructure clinical education around continuity. Many US medical schools have added longitudinal out-patient attachments to enhance student continuity with patients and supervising doctors. However, continuity with patients can be difficult to achieve and little is known about the independent effect of continuity with a supervising doctor and setting. This study describes students' perceptions of the types of continuity experienced in longitudinal attachments and the learning associated with continuity. This is a qualitative study using a grounded theory approach. Interviews were conducted with 12 Year 3 medical students about their continuity experiences with patients, supervisors and settings during their attachment. The resulting data were subjected to thematic analysis. Continuity with supervising doctors provided students with career mentorship and person...
Journal of graduate medical education, 2013
JAMA internal medicine, Jan 14, 2013
sis in this period that adjusted for these factors did not. 1 Recent studies suggest, however, th... more sis in this period that adjusted for these factors did not. 1 Recent studies suggest, however, that gender differences in earnings still exist even after adjustment for these factors. While it is important to study gender differences in earnings after accounting for factors such as specialty choice and practice type, it is equally important to understand overall unadjusted gender differences in earnings. This is because specialty and practice choices may be due to not only preferences of female physicians but also unequal opportunities. For example, are unadjusted earnings differences between male and female physicians due to a preference of female physicians for lower-paying specialties (eg, pediatrics or primary care) or do female physicians have less opportunity to enter higher paying specialties despite having similar preferences as male physicians? The etiology of the persistent gender gap in physician earnings is unknown and merits further consideration.
BMJ quality & safety, 2011
The outbreak of HIV in the early 1980s saw widespread activism among patients and community suppo... more The outbreak of HIV in the early 1980s saw widespread activism among patients and community supporters. The author, a young physician in San Francisco at the time, describes how coming of age as a clinician in the midst of this activism affected her concept of the patient-physician relationship. The insistence of a particular patient, Robert, on specifying his treatment goals illustrates that even people with substantial cognitive challenges can participate in their own care in an egalitarian and active manner.
Journal of General Internal Medicine, Mar 1, 2011
Acad Med, 2001
The Interdisciplinary Generalist Curriculum (IGC) Project created curricular changes at the parti... more The Interdisciplinary Generalist Curriculum (IGC) Project created curricular changes at the participating schools with very little direct financial support. A reconsideration of the process of this national effort reveals many intangible elements that were as critical to the project's successes as were the direct dollars. Those factors included careful attention to the criteria for school selection, specific project requirements that allowed institutional flexibility in project evolution, national assistance in program implementation, early and ongoing national recognition for project schools, and a highly organized, involved, and goal-oriented national organization. This national initiative provides a successful model for future funding of projects in this era of dwindling financial support for medical education innovation.
Http Dx Doi Org 10 1089 Jpm 2000 3 7, Apr 19, 2005
Teaching medical students to respond to needs of the dying represents an important challenge for ... more Teaching medical students to respond to needs of the dying represents an important challenge for medical educators. This article describes the goals and objectives that should be identified before medical schools can meet this challenge, as well as strategies that, when implemented, will provide students with the necessary knowledge, skills, and attitudes to meet the needs of the dying patients. The goals and objectives were identified through a modified group consensus process developed during Choice In Dying's 5-year project "Integrating Education on Care of the Dying into Medical Schools." The authors have diverse experiences and backgrounds and are actively involved in death and dying teaching at 11 medical schools. They conclude that after accepting the goals and objectives, key medical school faculty can work cooperatively to develop strategies to integrate them into the school's curriculum. Without first establishing a set of goals and objectives and developing evaluation methods, medical schools could miss their mark in fostering the student's ability to care for the dying.
QRB. Quality review bulletin
Western Journal of Medicine
Annals of internal medicine
Voluntary screening for human immunodeficiency virus (HIV) infection may help prevent the spread ... more Voluntary screening for human immunodeficiency virus (HIV) infection may help prevent the spread of the HIV epidemic if persons who test positive alter behaviors that may transmit infection. Protecting persons from unknowingly being exposed to HIV infection must be balanced against respecting the autonomy of individuals being screened. Seropositive patients may feel a stigma and be subjected to discrimination if confidentiality of test results is breached. In patients without high-risk behaviors, the positive predictive value of HIV testing may be substantially increased if tests are done in reference laboratories and if further confirmatory tests are run on a second blood specimen. For persons with high-risk behaviors, HIV testing can be recommended to those who want to reduce uncertainty about their HIV status or whose medical care would change if they were seropositive. Health care workers can maximize benefits of screening and minimize harm by educating and counseling patients before HIV testing, discussing the confidentiality of HIV test results, urging patients to disclose positive test results to sex partners, and advising patients on how to reduce high-risk behaviors.
The authors describe the first four years (1995-1998) in which the University of California, San ... more The authors describe the first four years (1995-1998) in which the University of California, San Francisco School of Medicine operated an evaluation system to monitor students' professional behaviors longitudinally through their clinical rotations. The goals of this system are to help "turn around" students found to have behaved unprofessionally, to demonstrate the priority placed by the school on the attainment of professional behavior, and to give the school "muscle" to deal with issues of professionalism. A student whose professional skills are rated less than solid at the end of the clerkship receives a "physicianship report" of unprofessional behavior. If the student receives such a report from two or more clerkships, he or she is placed on academic probation that can lead to dismissal even if passing grades are attained in all rotations. Counseling services and mentoring by faculty are provided to such students to improve their professional behaviors. From 1995 to 1998, 29 reports of unprofessional behavior on the part of 24 students were submitted to the dean's office; five students received two reports. The clerkship that submitted the most reports was obstetrics-gynecology. The most common complaint for the five students who received two reports was a poor relationship with the health care team. Four of these students had their difficulties cited in their dean's letters and went on to residency; the fifth voluntarily withdrew from medical school. The authors describe the students' and faculty members' responses to the system, discus lessons learned, difficulties, and continuing issues, review future plans (e.g., the system will be expanded to the first two years of medical school), and reflect on dealing with issues of professionalism in medical school and the importance of a longitudinal (i.e., not course-by-course) approach to monitoring students' behaviors. The authors plan to compare the long-range performances of students identified by the evaluation system with those of their classmates.
Western Journal of Medicine
Ethnicity & disease
To determine whether ethnic and other social factors affect how frequently do-not-resuscitate (DN... more To determine whether ethnic and other social factors affect how frequently do-not-resuscitate (DNR) orders are written, the timing of DNR orders, or patient involvement in the DNR decision. Retrospective cohort. Patients who died in one urban teaching hospital on the medicine, cardiology, or family practice service during 1988 were eligible; 288 were included in the analyses. Chi-square tests and logistic regression were used to examine frequency of DNR orders and patient involvement; analysis of variance and linear regression were used to examine timing of the DNR orders. Non-whites were more likely than whites to have DNR orders (OR 1.76; 95% CI, 1.09-2.84) but timing of the DNR order did not vary significantly by race/ethnicity. Patients who spoke English fluently were more likely to be involved in the DNR decision than those who did not (OR 1.28; 95% CI, 1.01-1.61). Patients with documented human immunodeficiency virus were more likely than uninfected patients to have DNR orders (OR 3.51; 95% CI, 1.36-9.02), to be involved in the decision (OR 10.11; 95% CI, 4.87-21.00); and to have DNR orders written earlier (P = 0.02). Alcoholic patients were more likely than non-alcoholics to have DNR orders (OR 1.17; 95% CI, 1.04-1.33). Ethnic and other social factors do appear to play a role in DNR decisions. It needs to be determined if these differences are due to patient preferences or clinician characteristics.
Academic Medicine
At most medical schools students spend the core clerkship year entirely in clinical settings, geo... more At most medical schools students spend the core clerkship year entirely in clinical settings, geographically dispersed, and assigned to separate teams. Because of the immediacy of experiential learning in the clinical environment, this year is often the highlight of medical school. However, the intensity of the experience and the dispersion of students poses serious challenges to student well being and professional development, and to meeting important educational objectives best taught in the clinical year but difficult to implement in competition with direct patient care. To address these challenges in a way that does not interfere with the clinical experiences, we developed and are implementing three one-week intersessions. These are designated weeks between clerkship rotations when all third-year students are "off rotations" and studying together in an integrative, collaborative and reflective manner. We identified themes for the intersession course from several source...
AIDS Education and Prevention
Physicians can help prevent transmission of HIV by assessing HIV positive patients for risky sexu... more Physicians can help prevent transmission of HIV by assessing HIV positive patients for risky sexual and needle-sharing behaviors, and by providing risk reduction counseling. From 1995 to 1997, we gathered data on the HIV transmission prevention assessment and counseling practices of 44 San Francisco Bay area physicians in face-to-face, semistructured interviews. A refined coding scheme and constant comparative analytic method were used. Although physicians varied in their responses to coded items, two styles of engagement, at the extremes, emerged from the data: "consultant" and "collaborator." Consultants conducted transmission prevention assessment and counseling during initial visits or upon medical cues (e.g., presence of sexually transmitted diseases) and viewed themselves primarily as information sources, whereas collaborators regularly conducted transmission prevention counseling and viewed themselves as actively helping patients reduce transmission risk. ...
Clinical journal of the American Society of Nephrology : CJASN, Jan 7, 2014
The American College of Physicians recently published a guideline on screening for CKD that recom... more The American College of Physicians recently published a guideline on screening for CKD that recommends against screening for CKD in asymptomatic adults without risk factors. The generally accepted criteria for population-based screening for disease state that screening should improve important clinical outcomes while limiting harms for those individuals screened. However, CKD screening does not meet these criteria. There is currently no evidence evaluating or demonstrating benefits for providing early treatment for patients identified via screening who do not have risk factors. On the other hand, harms are associated with the screening and include false-positive results, unnecessary testing and treatment, and disease labeling.
Medical education, 2009
Concerns about the quality of medical student learning experiences during traditional clerkships ... more Concerns about the quality of medical student learning experiences during traditional clerkships have prompted calls to restructure clinical education around continuity. Many US medical schools have added longitudinal out-patient attachments to enhance student continuity with patients and supervising doctors. However, continuity with patients can be difficult to achieve and little is known about the independent effect of continuity with a supervising doctor and setting. This study describes students' perceptions of the types of continuity experienced in longitudinal attachments and the learning associated with continuity. This is a qualitative study using a grounded theory approach. Interviews were conducted with 12 Year 3 medical students about their continuity experiences with patients, supervisors and settings during their attachment. The resulting data were subjected to thematic analysis. Continuity with supervising doctors provided students with career mentorship and person...
Journal of graduate medical education, 2013
JAMA internal medicine, Jan 14, 2013
sis in this period that adjusted for these factors did not. 1 Recent studies suggest, however, th... more sis in this period that adjusted for these factors did not. 1 Recent studies suggest, however, that gender differences in earnings still exist even after adjustment for these factors. While it is important to study gender differences in earnings after accounting for factors such as specialty choice and practice type, it is equally important to understand overall unadjusted gender differences in earnings. This is because specialty and practice choices may be due to not only preferences of female physicians but also unequal opportunities. For example, are unadjusted earnings differences between male and female physicians due to a preference of female physicians for lower-paying specialties (eg, pediatrics or primary care) or do female physicians have less opportunity to enter higher paying specialties despite having similar preferences as male physicians? The etiology of the persistent gender gap in physician earnings is unknown and merits further consideration.
BMJ quality & safety, 2011
The outbreak of HIV in the early 1980s saw widespread activism among patients and community suppo... more The outbreak of HIV in the early 1980s saw widespread activism among patients and community supporters. The author, a young physician in San Francisco at the time, describes how coming of age as a clinician in the midst of this activism affected her concept of the patient-physician relationship. The insistence of a particular patient, Robert, on specifying his treatment goals illustrates that even people with substantial cognitive challenges can participate in their own care in an egalitarian and active manner.