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Moving Forward in GME Reform: A 4 + 1 Model of Resident Ambulatory Training
BACKGROUND
Traditional ambulatory training models have limitations in important domains, including opportunities for residents to learn, fragmentation of care delivery experience, and satisfaction with ambulatory experiences. New models of ambulatory training are needed.
AIM
To compare the impact of a traditional ambulatory training model with a templated 4 + 1 model.
SETTING
A large university-based internal medicine residency using three different training sites: a patient-centered medical home, a hospital-based ambulatory clinic, and community private practices.
PARTICIPANTS
Residents, faculty, and administrative staff.
PROGRAM DESCRIPTION
Development of a templated 4 + 1 model of residency where trainees do not attend to inpatient and outpatient responsibilities simultaneously.
PROGRAM EVALUATION
A mixed-methods analysis of survey and nominal group data measuring three primary outcomes: 1) Perception of learning opportunities and quality of faculty teaching; 2) Reported fragmentation of care delivery experience; 3) Satisfaction with ambulatory experiences. Self-reported empanelment was a secondary outcome. Residents’ learning opportunities increased (
p
= 0.007) but quality of faculty teaching was unchanged. Participants reported less fragmentation in the care residents provide patients in the inpatient and outpatient setting (
p
< 0.0001). Satisfaction with ambulatory training improved (
p
< 0.0001). Self-reported empanelment also increased (
p
< 0.0001). Results held true for residents, faculty, and staff at all three ambulatory training sites (
p
< 0.0001).
DISCUSSION
A 4 + 1 model increased resident time in ambulatory continuity clinic, enhanced learning opportunities, reduced fragmentation of care residents provide, and improved satisfaction with ambulatory experiences. More studies of similar models are needed to evaluate effects on additional trainee and patient outcomes.
Journal Article
Unpacking Resident-Led Code Status Discussions: Results from a Mixed Methods Study
ABSTRACT
BACKGROUND
The quality of code status discussions (CSDs) is suboptimal as physicians often fail to discuss patients’ goals of care and resuscitation outcomes. We previously demonstrated that internal medicine residents randomized to a communication skills intervention scored higher than controls on a CSD checklist using a standardized patient. However, the impact of this training on CSD content is unknown.
OBJECTIVE
Compare CSD content between intervention and control residents.
DESIGN
We conducted qualitative analysis of simulated CSDs. Augmenting a priori codes with constant comparative analysis, we identified key themes associated with resident determination of code status. We dichotomized each theme as present or absent. We used chi-square tests to evaluate the association between training and presence of each theme.
PARTICIPANTS
Fifty-six residents rotating on the internal medicine service in July 2010 were randomized to intervention (
n
= 25) or control (
n
= 31).
INTERVENTION
Intervention residents completed CSD skills training (lectures, deliberate practice, and self-study). Six months later, all 56 residents completed a simulated CSD.
MAIN MEASURE
Comparison of key themes identified in CSDs among intervention and controls.
KEY RESULTS
Fifty-one transcripts were recorded and reviewed. Themes identified included: exploration of patient values/goals, framing code status as a patient decision, discussion of resuscitation outcomes and quality of life, and making a recommendation regarding code status. Intervention residents were more likely than controls to explore patient values/goals (
p
= 0.002) and make a recommendation (
p
< 0.001); and less likely to frame the decision as one solely to be made by the patient (
p
= 0.01). Less than one-third of residents discussed resuscitation outcomes or quality of life.
CONCLUSION
Training positively influenced CSD content in key domains, including exploration of patient values/goals, making a recommendation regarding code status, and not framing code status as solely a patient decision. However, despite the intervention, residents infrequently discussed resuscitation outcomes and quality of life.
Journal Article
Internal Medicine Residents’ Attitudes Toward Simulated Depressed Cardiac Patients During an Objective Structured Clinical Examination: A Randomized Study
BackgroundPhysician biases toward mental conditions such as depression have been shown to adversely affect medical outcomes.ObjectiveTo explore the relationship between residents’ explicit bias toward depressed patients and their clinical skills on a cardiac case during an objective structured clinical exam (OSCE).DesignProspective parallel randomized controlled study.ParticipantsOne hundred eighty-five internal medicine residents from three residency programs in two states.InterventionDuring October–November 2015, residents were randomized to either a depressed or non-depressed standardized patient (SP) presenting with acute chest pain.Main MeasuresThe Medical Condition Regard Scale (MCRS) assessed residents’ explicit bias toward patients with depression. Their clinical skills (history-taking, physical examination, patient counseling, patient–physician interaction (PPI), differential diagnosis, and workup plan) and facial expressions were rated during an OSCE.Key ResultsNo significant relationships were found between resident explicit bias and clinical skill measurements. Residents who examined the depressed SP scored lower, on average, on history-taking (t [183] = −2.77, p < 0.01, Cohen’s d = 0.41) and higher on PPI (t [183] = 2.24, p < 0.05, Cohen’s d = 0.33) than residents examining the non-depressed SP. There were no differences, on average, between stations on physical examination, counseling, correct diagnosis, workup plan, or overall SP satisfaction. Facial recognition software demonstrated that residents with a non-depressed SP had more neutral expressions than depressed-SP residents (t [133] = −2.46, p < 0.05, Cohen’s d = 0.46), and residents with a depressed SP had more disgusted expressions than non-depressed-SP residents (t [83.52] = 2.10, p < 0.05, Cohen’s d = 0.28).ConclusionsExtrinsic bias did not predict OSCE performance in this study. Some differences were noted in the OSCE performance between the two stations. Further study is needed to examine the effects of patient mental health conditions on physician examination procedures, diagnostic behaviors, and patient outcomes.
Journal Article
A tool for prediction of risk of rehospitalisation and mortality in the hospitalised elderly: secondary analysis of clinical trial data
Objectives To construct and internally validate a risk score, the ‘80+ score’, for revisits to hospital and mortality for older patients, incorporating aspects of pharmacotherapy. Our secondary aim was to compare the discriminatory ability of the score with that of three validated tools for measuring inappropriate prescribing: Screening Tool of Older Person's Prescriptions (STOPP), Screening Tool to Alert doctors to Right Treatment (START) and Medication Appropriateness Index (MAI). Setting Two acute internal medicine wards at Uppsala University hospital. Patient data were used from a randomised controlled trial investigating the effects of a comprehensive clinical pharmacist intervention. Participants Data from 368 patients, aged 80 years and older, admitted to one of the study wards. Primary outcome measure Time to rehospitalisation or death during the year after discharge from hospital. Candidate variables were selected among a large number of clinical and drug-specific variables. After a selection process, a score for risk estimation was constructed. The 80+ score was internally validated, and the discriminatory ability of the score and of STOPP, START and MAI was assessed using C-statistics. Results Seven variables were selected. Impaired renal function, pulmonary disease, malignant disease, living in a nursing home, being prescribed an opioid or being prescribed a drug for peptic ulcer or gastroesophageal reflux disease were associated with an increased risk, while being prescribed an antidepressant drug (tricyclic antidepressants not included) was linked to a lower risk of the outcome. These variables made up the components of the 80+ score. The C-statistics were 0.71 (80+), 0.57 (STOPP), 0.54 (START) and 0.63 (MAI). Conclusions We developed and internally validated a score for prediction of risk of rehospitalisation and mortality in hospitalised older people. The score discriminated risk better than available tools for inappropriate prescribing. Pending external validation, this score can aid in clinical identification of high-risk patients and targeting of interventions.
Journal Article
Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medicine Clerkship Directors
BackgroundRecent reports, including the Institute of Medicine’s Improving Diagnosis in Health Care, highlight the pervasiveness and underappreciated harm of diagnostic error, and recommend enhancing health care professional education in diagnostic reasoning. However, little is known about clinical reasoning curricula at US medical schools.ObjectiveTo describe clinical reasoning curricula at US medical schools and to determine the attitudes of internal medicine clerkship directors toward teaching of clinical reasoning.DesignCross-sectional multicenter study.ParticipantsUS institutional members of the Clerkship Directors in Internal Medicine (CDIM).Main MeasuresExamined responses to a survey that was emailed in May 2015 to CDIM institutional representatives, who reported on their medical school’s clinical reasoning curriculum.Key ResultsThe response rate was 74% (91/123). Most respondents reported that a structured curriculum in clinical reasoning should be taught in all phases of medical education, including the preclinical years (64/85; 75%), clinical clerkships (76/87; 87%), and the fourth year (75/88; 85%), and that more curricular time should be devoted to the topic. Respondents indicated that most students enter the clerkship with only poor (25/85; 29%) to fair (47/85; 55%) knowledge of key clinical reasoning concepts. Most institutions (52/91; 57%) surveyed lacked sessions dedicated to these topics. Lack of curricular time (59/67, 88%) and faculty expertise in teaching these concepts (53/76, 69%) were identified as barriers.ConclusionsInternal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.
Journal Article
In the Wake of the 2003 and 2011 Duty Hours Regulations, How Do Internal Medicine Interns Spend Their Time?
ABSTRACT
BACKGROUND
The 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) common program requirements compress busy inpatient schedules and increase intern supervision. At the same time, interns wrestle with the effects of electronic medical record systems, including documentation needs and availability of an ever-increasing amount of stored patient data.
OBJECTIVE
In light of these changes, we conducted a time motion study to determine how internal medicine interns spend their time in the hospital.
DESIGN
Descriptive, observational study on inpatient ward rotations at two internal medicine residency programs at large academic medical centers in Baltimore, MD during January, 2012.
PARTICIPANTS
Twenty-nine interns at the two residency programs.
MAIN MEASURES
The primary outcome was percent of time spent in direct patient care (talking with and examining patients). Secondary outcomes included percent of time spent in indirect patient care, education, and miscellaneous activities (eating, sleeping, and walking). Results were analyzed using multilevel regression analysis adjusted for clustering at the observer and intern levels.
KEY RESULTS
Interns were observed for a total of 873 hours. Interns spent 12 % of their time in direct patient care, 64 % in indirect patient care, 15 % in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40 % of interns’ time. There was no significant difference in time spent in these activities between the two sites.
CONCLUSIONS
Interns today spend a minority of their time directly caring for patients. Compared with interns in time motion studies prior to 2003, interns in our study spent less time in direct patient care and sleeping, and more time talking with other providers and documenting. Reduced work hours in the setting of increasing complexity of medical inpatients, growing volume of patient data, and increased supervision may limit the amount of time interns spend with patients.
Journal Article
Brigham Intensive Review of Internal Medicine
Based upon the popular review course from Harvard Medical School, The Brigham Intensive Review of Internal Medicine is a comprehensive study guide for the American Board of Internal Medicine certification or maintenance of certification examination as well as for general practice review by physicians and residents.
eBook
Reducing the Prescribing of Heavily Marketed Medications: A Randomized Controlled Trial
Context
Prescription drug costs are a major component of health care expenditures, yet resources to support evidence-based prescribing are not widely available.
Objective
To evaluate the effectiveness of computerized prescribing alerts, with or without physician-led group educational sessions, to reduce the prescribing of heavily marketed hypnotic medications.
Design
Cluster-randomized controlled trial.
Setting
We randomly allocated 14 internal medicine practice sites to receive usual care, computerized prescribing alerts alone, or alerts plus group educational sessions.
Measurements
Proportion of heavily marketed hypnotics prescribed before and after the implementation of computerized alerts and educational sessions.
Main Results
The activation of computerized alerts held the prescribing of heavily marketed hypnotic medications at pre-intervention levels in both the alert-only group (adjusted risk ratio [RR] 0.97; 95% CI 0.82–1.14) and the alert-plus-education group (RR 0.98; 95% CI 0.83–1.17) while the usual-care group experienced an increase in prescribing (RR 1.31; 95% CI 1.08–1.60). Compared to the usual-care group, the relative risk of prescribing heavily marketed medications was less in both the alert-group (Ratio of risk ratios [RRR] 0.74; 95% CI 0.57–0.96) and the alert-plus-education group (RRR 0.74; 95% CI 0.58–0.97). The prescribing of heavily marketed medications was similar in the alert-group and alert-plus-education group (RRR 1.02; 95% CI 0.80–1.29). Most clinicians reported that the alerts provided useful prescribing information (88%) and did not interfere with daily workflow (70%).
Conclusions
Computerized decision support is an effective tool to reduce the prescribing of heavily marketed hypnotic medications in ambulatory care settings.
Trial Registration
clinicaltrials.gov Identifier: NCT00788346.
Journal Article