Miller, Nathaniel

Background and Objectives: Teaching medical students patient-centered approaches to weight loss counseling occurs in myriad ways. We examined lectures and direct faculty observation to see which was associated with better patient-centered care in medical students, measured by both self-perception and independent observer evaluation. Methods: Third- and fourth-year students attending one medical school were surveyed regarding their education in (1) weight loss and health behavior counseling, (2) obesity stigma, and (3) whether they had experienced direct faculty observation of their weight loss counseling. Several weeks later, the students were observed during a standardized patient encounter for obesity and an obesity-relevant comorbidity. A postencounter survey assessed overall student satisfaction with the encounter and with the care they provided. Independent coders rated their patient-centered communication using a validated measure. Results: There was no consistent association between any dependent variable and student ratings of adequacy of instruction, nor with instructional content. Direct faculty observation was not associated with overall encounter satisfaction or their overall patient-centeredness. However, experiences with direct faculty observation were significantly and positively associated with students’ perceptions of patient engagement (b=0.1, P=.05), and with independent coders’ ratings of student friendliness (b=0.13, P=.01), responsiveness (b=0.113, P=.03), and lower student anxiety (b=-0.1, P=.01). Conclusions: Independent observation and self-report of instruction adequacy and content had no consistent association with care quality. However, direct faculty observation predicted improvement in both student self-reports and independent observer ratings of students’ interpersonal quality of care. Further work is needed to define optimal methods of imparting patient-centered care.

A 19-year-old male presented to the clinic and was found to be prehypertensive and have proteinuria on urine testing. He was subsequently diagnosed with focal segmental glomerulosclerosis (FSGS). Initial workup for pediatric hypertension includes urinalysis, chemistry panel, lipid panel, and renal ultrasound. Abnormalities on urinalysis, including proteinuria, hypercholesterolemia, and low serum albumin in children are characteristic of nephrotic disease. FSGS is a type of kidney pathology that often contributes to nephrotic disease and results from a variety of causes. For the primary care provider, being aware of the guidelines for pediatric hypertension screening and evaluation is important as 20% of children with hypertensive disease are due to kidney disease. FSGS is the third leading cause of end-stage renal disease in children aged 12 to 19 years, and its incidence was found to be rising in a study of Olmsted County, MN residents. Treatment to complete or partial remission of the proteinuria can slow the progression of renal disease. In this case report, we will discuss the evaluation of pediatric hypertension workup with proteinuria, specifically due to FSGS, and review current management strategies.