The full-time clinical faculty: what goes around, comes around.

Acad Med. 2010 Feb;85(2):260-5

Authors: Barzansky B, Kenagy G

In his 1910 report entitled Medical Education in the United States and Canada, Abraham Flexner advanced an ideal model of medical education that included a university-based, full-time, salaried faculty whose time was devoted to teaching and research. This article traces the evolution of the “full-time” concept for clinical faculty and describes factors that have affected its implementation. Between 1910 and the 1930s, the full-time system for clinical faculty was implemented at a limited number of medical schools, but lack of financing made the system generally unworkable. The implementation of the “geographic” full-time concept during the 1940s to 1960s allowed faculty to be considered full-time while earning much of their income from clinical practice. Even then, there were concerns that medical schools would bring pressure on such faculty to increase their clinical activity for the purpose of supporting the institution. After the rise of private and public payers, clinical practice income came to be an explicit and increasingly important source of medical school revenue. This stimulated a significant expansion in the number of full-time clinical faculty over the next 40 years. In the 100 years following the Flexner Report, clinical faculty became “full-time” and “salaried,” but not in the way Flexner imagined. Instead of deriving their salaries from the resources of the medical school, they are significantly contributing to institutional financing through their practice. Flexner’s concern about the “distraction” of clinical practice interfering with faculty participation in education has come full circle, remaining a primary issue in medical education today.

PMID: 20107352 [PubMed - in process]

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The patient panel conference experience: what patients can teach our residents about competency issues.

Acad Med. 2009 Dec;84(12):1833-9

Authors: Colbert CY, Mirkes C, Cable CT, Sibbitt SJ, VanZyl GO, Ogden PE

PURPOSE: In 2007, the Scott & White/Texas A&M HSC College of Medicine began requiring all internal medicine residents to attend quarterly patient panel conferences, during which former Scott & White patients speak frankly about their inpatient and outpatient experiences. The main purpose of this mixed-methods pilot study was to determine whether residents' competency education could be enhanced via the conferences. METHOD: Of the 54 internal medicine residents in the residency program, 31, 39, and 41 participated in three patient panel conferences, respectively, between December 2007 and August 2008. Each resident completed an assessment that included a reflection on his or her own practice and the identification of competency issues highlighted by patients' oral narratives. Content analyses of responses to open-ended questions were performed. Consensus on themes was reached. Descriptive statistics were run on quantitative data. RESULTS: Six themes were identified: improve communication with patients/families, improve patient care, improve professional behaviors, empathize with patients/families, display sensitivity to patients'/families' needs/concerns, and recognize system issues. When asked if the conference highlighted competency problems, residents answered "agree" or "strongly agree" as follows: 82% for professionalism, 82.9% for systems-based practice, 85.2% for interpersonal and communication skills, and 84.4% for patient care. The majority were able to provide examples of competency issues. CONCLUSIONS: The patient panel conference experience was a powerful mechanism for enhancing competency education. The conferences were an effective means of presenting real-life examples of systems issues in the context of a hospital system.

PMID: 19940596 [PubMed - indexed for MEDLINE]

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Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature.

Acad Med. 2009 Dec;84(12):1775-1787

Authors: Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, Padmore JS, Karpovich KP

PURPOSE: Effective communication is central to patient safety. There is abundant evidence of negative consequences of poor communication and inadequate handoffs. The purpose of the current study was to conduct a systematic review of articles focused on physicians’ handoffs, conduct a qualitative review of barriers and strategies, and identify features of structured handoffs that have been effective. METHOD: The authors conducted a thorough, systematic review of English-language articles, indexed in PubMed, published between 1987 and June 2008, and focused on physicians’ handoffs in the United States. The search strategy yielded 2,590 articles. After title review, 401 were obtained for further review by trained abstractors. RESULTS: Forty-six articles met inclusion criteria, 33 (71.7%) of which were published between 2005 and 2008. Content analysis yielded 91 handoffs barriers in eight major categories and 140 handoffs strategies in seven major categories. Eighteen articles involved research on handoffs. Quality assessment scores for research studies ranged from 1 to 13 (possible range 1-16). One third of the reviewed research studies obtained quality scores at or below 8, and only one achieved a score of 13. Only six studies included any measure of handoff effectiveness. CONCLUSIONS: Despite the negative consequences of inadequate physicians’ handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.

PMID: 19940588 [PubMed - as supplied by publisher]

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“Renters” or “Owners”? Residents’ Perceptions and Behaviors Regarding Error Reduction in Teaching Hospitals: A Literature Review.

Acad Med. 2009 Dec;84(12):1765-1774

Authors: Padmore JS, Jaeger J, Riesenberg LA, Karpovich KP, Rosenfeld JC, Patow CA

PURPOSE: Residents' attitudes, practices, and behaviors vary in response to medical error within the context of the culture of their institutions. The purpose of this study was to conduct a systematic review of the literature focused on residents' attitudes and behaviors regarding medical errors in teaching hospitals, including a qualitative review of barriers and proposed countermeasures related to residents' engagement in patient safety. METHOD: The electronic literature databases of MEDLINE, CINAHL, and ERIC were searched for articles published between January 1988 and June 2008. The search strategy yielded 124 articles. A scoring system was developed to assess the quality of the overall literature. RESULTS: Nineteen studies met eligibility criteria, with 17 published since 2005. There were 12 cross-sectional, 5 qualitative, 1 cohort and 1 pre-post intervention study. Quality assessment scores ranged from 5.5 to 12.5 (possible range 1.0-16.0). Three studies obtained a score of </=8.0, 5 obtained scores of 8.5 to 10.5, and 11 studies had scores of 11.0 to 12.5. Personal, environmental, and system barriers, and environmental and system countermeasures, were identified. CONCLUSIONS: Although the published literature on this topic is limited, those articles that exist identify barriers that make residents reluctant to engage in institutional error identification and/or reduction. Key factors identified included a fear of retribution and the perception of residents as transient care providers. Whereas several countermeasures have been promulgated, the literature reveals scant evidence of their effectiveness. Institutions should recognize and capitalize on the unique experiences of residents and their potential to become owners in patient safety initiatives.

PMID: 19940587 [PubMed - as supplied by publisher]

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Perspective: Autonomic Care Systems for Hospitalized Patients.

Acad Med. 2009 Dec;84(12):1727-1731

Authors: Goldschmidt-Clermont PJ, Dong C, Rhodes NM, McNeill DB, Adams MB, Gilliss CL, Cuffe MS, Califf RM, Peterson ED, Lubarsky DA

With advancements of medical technology and improved diagnostic and treatment options, children with severe birth defects who would otherwise have no chance of surviving post birth survive to go home every day. The average lifespan in the United States has increased substantially over the last century. These successes and many other medical breakthroughs in managing complex illnesses, particularly in frail, elderly patients, have resulted in an increasing percentage of patients with comorbidities. This, coupled with a policy change by Medicare (i.e., Medicare will no longer reimburse hospitals for costs associated with treating preventable errors and injuries that a patient acquires while in the hospital), creates an enormous challenge to health care providers. To meet the challenge, the authors propose a new model of health care-the autonomic care system (ACS)-a concept derived from the intensive care unit and the autonomic computing initiative in the computer industry. Using wound care as an example, the authors examine the necessity, feasibility, design, and challenges related to ACS. Specifically, they discuss the role of the human operator, the potential combination of ACS and existing hospital information technology (e.g., electronic medical records and computerized provider order entry), and the costs associated with ACS. ACS may serve as a roadmap to revamp the health care system, bringing down the barriers among different specialties and improving the quality of care for each problem for all hospitalized patients.

PMID: 19940580 [PubMed - as supplied by publisher]

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Observation and Measurement of Hand Hygiene and Patient Identification Improve Compliance With Patient Safety Practices.

Acad Med. 2009 Dec;84(12):1705-1712

Authors: Rosenthal T, Erbeznik M, Padilla T, Zaroda T, Nguyen DH, Rodriguez M

Measurement, a crucial step in any quality improvement activity, is difficult in two important patient safety processes: hand hygiene and patient identification. This study describes a program at the UCLA Medical Center, called Measure to Achieve Patient Safety (MAPS), which uses undergraduate student volunteers to carry out observations in the hospital. This program has been an important part of UCLA's efforts for quality improvement in patient safety efforts. Since 2004, approximately 20 students per year plus two student leaders have been selected to participate in the MAPS program. They were trained in techniques of measuring and observation and in professional behavior. They participated in weekly and monthly meetings with program leadership, received continuing education from the UCLA patient safety staff, and were trained in observational measurement. The students' observational results have been systematically reported to clinicians and departmental and hospital leadership. Handwashing increased from 50% to 93%, and nurses' checking of two identifiers at the time of medication administration increased from 50% to 95%. Compliance with proper patient identification at the time of nurse-to-transporter handoffs of patients for procedures increased to >90%. This unique program has made a significant contribution to UCLA's quality, safety, and service programs. MAPS has been widely accepted by the clinical staff and has also been valuable to the student volunteers. Such an approach is easily adaptable to other academic medical centers.

PMID: 19940576 [PubMed - as supplied by publisher]

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Restructuring Within an Academic Health Center to Support Quality and Safety: The Development of the Center for Quality and Safety at the Massachusetts General Hospital.

Acad Med. 2009 Dec;84(12):1663-1671

Authors: Bohmer RM, Bloom JD, Mort EA, Demehin AA, Meyer GS

Recent focus on the need to improve the quality and safety of health care has created new challenges for academic health centers (AHCs). Whereas previously quality was largely assumed, today it is increasingly quantifiable and requires organized systems for improvement. Traditional structures and cultures within AHCs, although well suited to the tripartite missions of teaching, research, and clinical care, are not easily adaptable to the tasks of measuring, reporting, and improving quality. Here, the authors use a case study of Massachusetts General Hospital’s efforts to restructure quality and safety to illustrate the value of beginning with a focus on organizational culture, using a systematic process of engaging clinical leadership, developing an organizational framework dependent on proven business principles, leveraging focus events, and maintaining executive dedication to execution of the initiative. The case provides a generalizable example for AHCs of how applying explicit management design can foster robust organizational change with relatively modest incremental financial resources.

PMID: 19940570 [PubMed - as supplied by publisher]

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Understanding and Improving Inpatient Mortality in Academic Medical Centers.

Acad Med. 2009 Dec;84(12):1657-1662

Authors: Behal R, Finn J

The purpose of this article is to describe factors contributing to potentially preventable mortality in academic medical centers and the organizational characteristics associated with success in reducing mortality. Sixteen U.S. academic medical centers that wished to improve risk-adjusted inpatient mortality rates requested a consultation that included interviews with physicians, nurses, and hospital leaders; review of medical records; and evaluation of systems and processes of care. The assessments took place on-site; they identified key factors contributing to preventable mortality, and each hospital received specific recommendations. Changes in observed mortality and in the ratio of observed to expected mortality were measured from 2002 to final follow-up in 2007. Evaluations determined each hospital’s success factors and key barriers to improvement. The key factors contributing to preventable mortality were delays in responding to deteriorating patients, suboptimal critical care, hospital-acquired infections, postoperative complications, medical errors, and community issues such as the availability of hospice care. Of the 16 hospitals, 12 were able to reduce their mortality index. The five hospitals that had the greatest improvement in mortality were the only hospitals with a broad level of engagement among hospital and physician leaders, including the department chairs. In the hospitals whose performance did not improve, the department chairs were not engaged in the process. The academic medical centers that focused on mortality reduction and had engagement of physicians, especially department chairs, were able to achieve meaningful reductions in hospital mortality. The necessary ingredients for achieving meaningful improvement in clinical outcomes included good data, a sound method for change, and physician leadership.

PMID: 19940569 [PubMed - as supplied by publisher]

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Commentary: “Who Was Caring for Mary?” Revisited: A Call for All Academic Physicians Caring for Patients to Focus on Systems and Quality Improvement.

Acad Med. 2009 Dec;84(12):1648-1650

Authors: Southwick FS, Spear SJ

Over 15 years have passed since Mary’s near death (Annals of Internal Medicine. 1993;118:146-148). Disappointment in the care by fellow academic physicians persists; however, a reanalysis of her case through the lens of complex systems design and performance yields a more accurate and actionable perspective. Mary’s suffering was not due to human failure alone. Human failure was provoked and exacerbated by broken processes including ambiguous assignments of responsibility; inadequate transfers of information and authority; unreliable or unavailable protocols for providing safe, effective treatment; and a failure to integrate the deep but narrow perspectives of individual specialists into a complete picture of Mary’s condition. Her case exemplifies, in personal terms, many of the system challenges academic medical centers face: Faculty have other missions that can conflict with patient care; disease complexity is high, requiring input from multiple subspecialists; clinical departments serve as roadblocks to communication; and novice physicians, requiring close supervision, have primary responsibility for the day-to-day care of acutely ill patients. The academic physicians who first cared for Mary unwittingly accepted flawed systems, and they failed to work around them. At great monetary and emotional expense, last-minute heroics saved Mary. In a dysfunctional system, even the most conscientious physician may be viewed as uncaring. As Mary’s case so clearly illustrates, patients and their families see the system and the physician as one. Only by working to improve the systems of delivery will academic physicians again be consistently viewed as caring.

PMID: 19940566 [PubMed - as supplied by publisher]

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Perspective: Educating physicians to lead hospitals.

Acad Med. 2009 Oct;84(10):1348-51

Authors: Gunderman R, Kanter SL

The percentage of hospitals that are physician led has been steadily declining and now stands at or near an all-time low. What price do the health care system and the people it serves pay for this decline in physician leadership? What might health care look like if medical educators devoted more time and attention to developing future physicians as organizational leaders? What changes would medical schools need to make to prepare medical students to play such a role? What advantages might accrue for patients, communities, and physicians themselves if more hospitals were physician led? Because hospitals are a vital resource in caring for the sick, promoting health, and addressing the challenges facing the U.S. health care system, it is now more important than ever before to explore how medical education can complement its traditional focus on the molecular, cellular, and organismal levels of health and disease with insight into the organizational dimensions of patient care. The authors believe the time is ripe to rethink medical education’s role in preparing tomorrow’s physicians as leaders.

PMID: 19881420 [PubMed - in process]

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Doctors’ Stress Responses and Poor Communication Performance in Simulated Bad-News Consultations.

Acad Med. 2009 Nov;84(11):1595-1602

Authors: Brown R, Dunn S, Byrnes K, Morris R, Heinrich P, Shaw J

PURPOSE: No studies have previously evaluated factors associated with high stress levels and poor communication performance in breaking bad news (BBN) consultations. This study determined factors that were most strongly related to doctors’ stress responses and poor communication performance during a simulated BBN task. METHOD: In 2007, the authors recruited 24 doctors comprising 12 novices (i.e., interns/residents with 1-3 years’ experience) and 12 experts (i.e., registrars, medical/radiation oncologists, or cancer surgeons, with more than 4 years’ experience). Doctors participated in simulated BBN consultations and a number of control tasks. Five-minute-epoch heart rate (HR), HR variability, and communication performance were assessed in all participants. Subjects also completed a short questionnaire asking about their prior experience BBN, perceived stress, psychological distress (i.e., anxiety, depression), fatigue, and burnout. RESULTS: High stress responses were related to inexperience with BBN, fatigue, and giving bad versus good news. Poor communication performance in the consultation was related to high burnout and fatigue scores. CONCLUSIONS: These results suggest that BBN was a stressful experience for doctors even in a simulated encounter, especially for those who were inexperienced and/or fatigued. Poor communication performance was related to burnout and fatigue, but not inexperience with BBN. These results likely indicate that burnout and fatigue contributed to stress and poor work performance in some doctors during the simulated BBN task.

PMID: 19858823 [PubMed - as supplied by publisher]

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Doctors’ Stress Responses and Poor Communication Performance in Simulated Bad-News Consultations.

Acad Med. 2009 Nov;84(11):1595-1602

Authors: Brown R, Dunn S, Byrnes K, Morris R, Heinrich P, Shaw J

PURPOSE: No studies have previously evaluated factors associated with high stress levels and poor communication performance in breaking bad news (BBN) consultations. This study determined factors that were most strongly related to doctors’ stress responses and poor communication performance during a simulated BBN task. METHOD: In 2007, the authors recruited 24 doctors comprising 12 novices (i.e., interns/residents with 1-3 years’ experience) and 12 experts (i.e., registrars, medical/radiation oncologists, or cancer surgeons, with more than 4 years’ experience). Doctors participated in simulated BBN consultations and a number of control tasks. Five-minute-epoch heart rate (HR), HR variability, and communication performance were assessed in all participants. Subjects also completed a short questionnaire asking about their prior experience BBN, perceived stress, psychological distress (i.e., anxiety, depression), fatigue, and burnout. RESULTS: High stress responses were related to inexperience with BBN, fatigue, and giving bad versus good news. Poor communication performance in the consultation was related to high burnout and fatigue scores. CONCLUSIONS: These results suggest that BBN was a stressful experience for doctors even in a simulated encounter, especially for those who were inexperienced and/or fatigued. Poor communication performance was related to burnout and fatigue, but not inexperience with BBN. These results likely indicate that burnout and fatigue contributed to stress and poor work performance in some doctors during the simulated BBN task.

PMID: 19858823 [PubMed - as supplied by publisher]

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Is There a Relationship Between High-Quality Performance in Major Teaching Hospitals and Residents’ Knowledge of Quality and Patient Safety?

Acad Med. 2009 Nov;84(11):1510-1515

Authors: Pingleton SK, Horak BJ, Davis DA, Goldmann DA, Keroack MA, Dickler RM

PURPOSE: The relationship of the quality of teaching hospitals’ clinical performance to resident education in quality and patient safety is unclear. The authors studied residents’ knowledge of these areas in major teaching hospitals with higher- and lower-quality performance rankings. They assessed the presence of formal and informal quality curricula to determine whether programmatic differences exist. METHOD: The authors used qualitative research methodology with purposeful sampling. They gathered data from individual structured interviews with residents and key educational and quality leaders in six medical schools and teaching hospitals, which represented a range of quality performance rankings, geographic regions, and public or private status. RESULTS: No relationship emerged between a hospital’s quality status, residents’ curriculum, and the residents’ understanding of quality. Residents’ definitions of quality and safety and their knowledge of the practice-based learning and systems-based practice competencies were indistinguishable between hospitals. Residents in all programs had extensive patient safety knowledge acquired through an informal curriculum in the hospital setting. A formal curriculum existed in only two programs, both of them ambulatory settings. CONCLUSIONS: Residents’ learning about quality and patient safety is extensive, largely through a positive informal curriculum in the teaching hospital and, less frequently, via a formal curriculum. No relationship was found between the quality performance of the teaching hospital and the residents’ curriculum or understanding of quality or safety. Residents seem to learn through an informal curriculum provided by hospital initiatives and resources, and thus these data suggest the importance of major teaching hospitals in quality education.

PMID: 19858806 [PubMed - as supplied by publisher]

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Is There a Relationship Between High-Quality Performance in Major Teaching Hospitals and Residents’ Knowledge of Quality and Patient Safety?

Acad Med. 2009 Nov;84(11):1510-1515

Authors: Pingleton SK, Horak BJ, Davis DA, Goldmann DA, Keroack MA, Dickler RM

PURPOSE: The relationship of the quality of teaching hospitals’ clinical performance to resident education in quality and patient safety is unclear. The authors studied residents’ knowledge of these areas in major teaching hospitals with higher- and lower-quality performance rankings. They assessed the presence of formal and informal quality curricula to determine whether programmatic differences exist. METHOD: The authors used qualitative research methodology with purposeful sampling. They gathered data from individual structured interviews with residents and key educational and quality leaders in six medical schools and teaching hospitals, which represented a range of quality performance rankings, geographic regions, and public or private status. RESULTS: No relationship emerged between a hospital’s quality status, residents’ curriculum, and the residents’ understanding of quality. Residents’ definitions of quality and safety and their knowledge of the practice-based learning and systems-based practice competencies were indistinguishable between hospitals. Residents in all programs had extensive patient safety knowledge acquired through an informal curriculum in the hospital setting. A formal curriculum existed in only two programs, both of them ambulatory settings. CONCLUSIONS: Residents’ learning about quality and patient safety is extensive, largely through a positive informal curriculum in the teaching hospital and, less frequently, via a formal curriculum. No relationship was found between the quality performance of the teaching hospital and the residents’ curriculum or understanding of quality or safety. Residents seem to learn through an informal curriculum provided by hospital initiatives and resources, and thus these data suggest the importance of major teaching hospitals in quality education.

PMID: 19858806 [PubMed - as supplied by publisher]

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Perspective: A Perfect Storm: The Convergence of Bullet Points, Competencies, and Screen Reading in Medical Education.

Acad Med. 2009 Nov;84(11):1500-1504

Authors: Wear D

Three distinct phenomena are currently at play in medical education: (1) the pervasive use of PowerPoint in teaching, (2) the wholesale application of competency models, and (3) the shift from paper reading to screen reading regardless of course, text, or genre. Finding themselves placed at this intersection, students encounter fewer and fewer opportunities to practice some of the very cognitive and affective habits medical educators say they value in physicians, particularly critical reflection and deliberation, an eye for nuance, context, and ambiguity, and an appreciation that becoming a doctor involves more than learning content or performing skills. This article confronts these phenomena singly and then at their intersection, which may discourage, even dismantle, many of these habits. The author proposes that the rapid shift over the past decade to a technology-driven, competency-oriented environment in medical education is the medical educators’ creation, one that sets up conditions for a perfect cognitive storm.

PMID: 19858803 [PubMed - as supplied by publisher]

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