When Do Supervising Physicians Decide to Entrust Residents With Unsupervised Tasks?

Acad Med. 2010 Sep;85(9):1408-1417

Authors: Sterkenburg A, Barach P, Kalkman C, Gielen M, Ten Cate O

PURPOSE: Patient-care responsibilities stimulate trainee learning but training may compromise patient safety. The authors investigated factors guiding clinical supervisors’ decisions to trust residents with critical patient-care tasks. METHOD: In a mixed quantitative and qualitative descriptive study carried out at University Medical Center Utrecht, Utrecht, the Netherlands, from March to September 2008, the authors surveyed attending anesthetists and resident anesthetists regarding when attendings should entrust each of six selected critical tasks to residents. The authors conducted structured interviews with both groups, using trigger case vignettes to solicit opinions on factors that affect entrustment decisions. RESULTS: Thirty-two attending anesthetists and 31 residents answered the questionnaire (response rate 58%), and 10 participants from each group were interviewed. Attendings varied in their opinions regarding how much independence to give residents, particularly postgraduate year (PGY) 2, 3, and 4 residents. PGY1 residents reported working above their expected level of competence but estimate their own ability as sufficient, whereas PGY5 residents reported working below their expected level of competence. The authors classified factors that determine entrustment into four groups: characteristics of the resident, the attending, the clinical context, and the critical task. CONCLUSIONS: Residents’ and attendings’ opinions and impressions differ regarding what is expected from residents, what residents actually do, and what residents think they can do safely. The authors list factors affecting why and when supervisors trust residents to proceed without supervision. Future studies should address drivers behind entrustment decisions, correlations with patient outcomes, and tools that enable faculty to justify their entrustment decisions.

PMID: 20736669 [PubMed - as supplied by publisher]

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Taking note of the perceived value and impact of medical student chart documentation on education and patient care.

Acad Med. 2010 Sep;85(9):1440-4

Authors: Friedman E, Sainte M, Fallar R

PURPOSE: To determine the extent of restrictions to medical student documentation in patients’ records and the opinions of medical education leaders about such restrictions’ impact on medical student education and patient care. METHOD: Education deans (n = 126) of medical schools in the United States and Canada were surveyed to determine policies regarding placement of medical student notes in the patient record, the value of medical students’ documentation in the medical record, and the use of electronic medical records (EMRs) for patient notes. The instrument was a 23-item anonymous Web survey. RESULTS: Seventy-nine deans responded. Over 90% believed student notes belong in medical records, but only 42% had a policy regarding this. Ninety-three percent indicated that without student notes, student education would be negatively affected. Fewer (56%) indicated that patient care would be negatively affected. Most thought limiting students’ notes would negatively affect several other issues: feeling a part of the team (96%), preparation for internship (95%), and students’ sense of involvement (94%). Half (52%) reported that fourth-year students could place notes in paper charts at “all” affiliated hospitals, and 6% reported that fourth-year students could do so at “no” hospitals. CONCLUSIONS: Although students’ ability to enter notes in patients’ records is believed to be important for student education, only about half of all hospitals allow all students’ notes in the EMR. Policies regarding placement of student notes should be implemented to ensure students’ competency in note writing and their value as members of the patient care team.

PMID: 20736671 [PubMed - in process]

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Does Perspective-Taking Increase Patient Satisfaction in Medical Encounters?

Acad Med. 2010 Sep;85(9):1445-1452

Authors: Blatt B, Lelacheur SF, Galinsky AD, Simmens SJ, Greenberg L

PURPOSE: To assess whether perspective-taking, which researchers in other fields have shown to induce empathy, improves patient satisfaction in encounters between student-clinicians and standardized patients (SPs). METHOD: In three studies, randomly assigned students (N = 608) received either a perspective-taking instruction or a neutral instruction prior to a clinical skills examination in 2006-2007. SP satisfaction was the main outcome in all three studies. Study 1 involved 245 third-year medical students from two universities. Studies 2 and 3 extended Study 1 to examine generalizability across student and SP subpopulations. Study 2 (105 physician assistant students, one university) explored the effect of perspective-taking on African American SPs’ satisfaction. Study 3 (258 third-year medical students, two universities) examined the intervention’s effect on students with high and low baseline perspective-taking tendencies. RESULTS: Intervention students outscored controls in patient satisfaction in all studies: Study 1: P = .01, standardized effect size = 0.16; Study 2: P = .001, standardized effect size = 0.31; Study 3: P = .009, standardized effect size = 0.13. In Study 2, perspective-taking improved African American SPs’ satisfaction. In Study 3, intervention students with high baseline perspective-taking tendencies outscored controls (P = .0004, standardized effect size = 0.25), whereas those with low perspective-taking tendencies did not (P = .72, standardized effect size = 0.00). CONCLUSIONS: Perspective-taking increased patient satisfaction in all three studies, across medical schools, clinical disciplines, and racially diverse students and SPs. Perspective-taking as a means for improving patient satisfaction deserves further exploration in clinical training and practice.

PMID: 20736672 [PubMed - as supplied by publisher]

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Cost-Effectiveness of a Hospitalist Service in a Public Teaching Hospital.

Acad Med. 2010 Aug;85(8):1312-1315

Authors: Lundberg S, Balingit P, Wali S, Cope D

PURPOSE: The authors report implementing an academic hospitalist team as a cost-effective solution to the problem of an inpatient census that exceeds their public hospital’s teaching service limits. Medi-Cal (California’s Medicaid program) per diem reimbursement was the primary source of revenue, which rendered moot some traditional advantages of hospitalist services. METHOD: The authors assessed cost-effectiveness by comparing average inpatient census, payment denial rate, and Medi-Cal reimbursement for internal medicine in 2008 and in 2007. They also focused on Medi-Cal patients admitted with low-risk chest pain in 2008, comparing the length-of-stay and denied-day rate data with data from 2005. RESULTS: Overall Medi-Cal reimbursement was $2,310,000 higher in 2008 than in 2007. Overall payment denial rate fell from 29% to 27.4%, while yearly admissions increased from 8,069 to 8,643, and the average daily census increased from 97.7 to 107.1 patients. For low-risk chest pain admissions, length of stay decreased from 2.48 to 1.92 days, denial rate decreased from 43.8% to 31.8%, and average reimbursement per inpatient day increased from $787 to $955. Total salary outlay for the first year of the service was approximately $310,000. CONCLUSIONS: By reducing payment denials and increasing the inpatient census, hospitalists were able to more than offset their compensation with a substantial increase in revenue under per diem reimbursement, which adds a new dimension to prior reports of cost-effectiveness of hospitalist services in diagnosis-based, capitated, or fee-for-service reimbursement systems. Hospitalists are a cost-effective solution to the problem of increasing inpatient workloads at public teaching hospitals.

PMID: 20671457 [PubMed - as supplied by publisher]

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Swapping Horses Midstream: Factors Related to Physicians’ Changing Their Minds About a Diagnosis.

Acad Med. 2010 Jul;85(7):1112-1117

Authors: Eva KW, Link CL, Lutfey KE, McKinlay JB

PURPOSE: Premature closure has been identified as the single most common cause of diagnostic error. This factorial experiment explored which variables exert an unconfounded influence on physicians’ diagnostic flexibility (changing their minds about the most likely diagnosis during a clinical case presentation). METHOD: In 2007-2008, 256 practicing physicians viewed a clinically authentic vignette simulating a patient presenting with possible coronary heart disease (CHD) and provided their initial impression midway through the case. At the end, they answered questions about the case, indicated how they would continue their clinical investigation, and made a final diagnosis. The authors used general linear models to determine which patient factors (age, gender, socioeconomic status, race), physician factors (gender, age/experience), and process variables were related to the likelihood of physicians’ changing their minds about the most likely diagnosis. RESULTS: Physicians who had less experience, those who named a non-CHD diagnosis as their initial impression, and those who did not ask for information about the patient’s prior cardiac disease history were the most likely to change their minds. Participants’ certainty in their initial diagnosis, the additional information desired, the diagnostic hypotheses generated, and the follow-up intended were not related to the likelihood of change in diagnostic hypotheses. CONCLUSIONS: Although efforts encouraging physicians to avoid cognitive biases and to reason in a more analytic manner may yield some benefit, this study suggests that experience is a more important determinant of diagnostic flexibility than is the consideration of additional diagnoses or the amount of additional information collected.

PMID: 20592506 [PubMed - as supplied by publisher]

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Studying the Effects of ACGME Duty Hours Limits on Resident Satisfaction: Results From VA Learners’ Perceptions Survey.

Acad Med. 2010 Jul;85(7):1130-1139

Authors: Kashner TM, Henley SS, Golden RM, Byrne JM, Keitz SA, Cannon GW, Chang BK, Holland GJ, Aron DC, Muchmore EA, Wicker A, White H

BACKGROUND: As the Accreditation Council on Graduate Medical Education (ACGME) deliberates over further limiting duty hours of graduate medical education (GME) trainees, few large-scale studies have shown residents to be satisfied with the effect the 2003 standards have had on clinical care, education outcomes, or working environments. This study measures the effect of the 2003 duty hours limits on resident-reported satisfaction with GME training during their rotations through the Department of Veterans Affairs (VA) medical centers from 2001 through 2007. METHOD: Self-reported satisfaction with clinical care and education environments were assessed by comparing responses to VA’s annual Learners’ Perceptions Survey administered before 2003 with responses administered after 2003. To measure duty hours effects on satisfaction, before-after differences were adjusted for covariate biases modeled after an exhaustive covariate search with 10-fold cross-validation. Because nonteaching controls are not available in satisfaction studies, we used a robust differencing variable technique to control before-after differences for trend biases in the simultaneous presence of missing data and possible model misspecification. RESULTS: There were 19,605 responders. Adjusting for covariate and trend biases, after the 2003 ACGME standards, 25% more residents in medicine specialties reported satisfaction with VA clinical environment and 11% more with VA preceptors and faculty. For surgery, 33% more residents reported satisfaction with VA clinical environment and 12% more with VA preceptors and faculty. Satisfaction with working environment was mixed. CONCLUSIONS: The 2003 ACGME duty hours standards were associated with improved satisfaction for resident clinical training and learning environments.

PMID: 20592508 [PubMed - as supplied by publisher]

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Can We Predict “Problem Residents”?

Acad Med. 2010 Jul;85(7):1147-1151

Authors: Brenner AM, Mathai S, Jain S, Mohl PC

PURPOSE: This study investigates whether data available at the time of residency application can be used to predict more accurately future problems of performance, both during and after residency. METHOD: The authors identified all residents with reported problematic behavior across 20 years (1987-2007) at a single residency program and created a set of matched controls. Problems were further divided into “major” (leading to significant disruptions of performance and disciplinary action) and “minor” (remediable and resolved). Application materials were then reviewed for United States Medical Licensing Examination (USMLE) scores, evidence of academic failures, interviewer ratings, negative interviewer comments, negative comments in the dean’s letter, and negative comments in letters of recommendation. RESULTS: The presence of any negative comments in the dean’s letter yielded significant correlations with future problems. Further, those applicants with future major problems had significantly more negative comments in the dean’s letter than did those with future minor problems. Other factors such as USMLE scores, failed courses, letters of recommendation, and interviewer ratings and comments did not predict future problems. CONCLUSIONS: Most of the factors the authors assessed in prospective applicants did not predict future problems, with the exception of negative (even mildly so) comments in the dean’s letter. The authors suggest that more attention should be paid to the use of the dean’s letter to assess risk among applicants, and prospective study of this assessment should be performed.

PMID: 20592510 [PubMed - as supplied by publisher]

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Teaching Quality Improvement and Patient Safety to Trainees: A Systematic Review.

Acad Med. 2010 Jun 10;

Authors: Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG

PURPOSE: To systematically review published quality improvement (QI) and patient safety (PS) curricula for medical students and/or residents to (1) determine educational content and teaching methods, (2) assess learning outcomes achieved, and (3) identify factors promoting or hindering curricular implementation. METHOD: Data sources included Medline (to January 2009), EMBASE, HealthSTAR, and article bibliographies. Studies selected reported curricula outlining specific educational content and teaching format. For articles with an evaluative component, the authors abstracted methodological features, such as study design. For all articles, they conducted a thematic analysis to identify factors influencing successful implementation of the included curricula. RESULTS: Of 41 curricula that met the authors’ criteria, 14 targeted medical students, 24 targeted residents, and 3 targeted both. Common educational content included continuous QI, root cause analysis, and systems thinking. Among 27 reports that included an evaluation, curricula were generally well accepted. Most curricula demonstrated improved knowledge. Thirteen studies (32%) successfully implemented local changes in care delivery, and seven (17%) significantly improved target processes of care. Factors that affected the successful curricular implementation included having sufficient numbers of faculty familiar with QI and PS content, addressing competing educational demands, and ensuring learners’ buy-in and enthusiasm. Participants in some curricula also commented on discrepancies between curricular material and local institutional practice or culture. CONCLUSIONS: QI and PS curricula that target trainees usually improve learners’ knowledge and frequently result in changes in clinical processes. However, successfully implementing such curricula requires attention to a number of learner, faculty, and organizational factors.

PMID: 20543652 [PubMed - as supplied by publisher]

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Toward Authentic Clinical Evaluation: Pitfalls in the Pursuit of Competency.

Acad Med. 2010 May;85(5):780-786

Authors: Ginsburg S, McIlroy J, Oulanova O, Eva K, Regehr G

PURPOSE: The drive toward competency-based education frameworks has created a tension between competing desires-for quantified, standardized measures on one hand, and for an authentic representation of what it means to be a good doctor on the other. The purpose of this study was to better understand the tensions that exist between competency frameworks and faculty’s real-life experiences in evaluating residents. METHOD: Interviews were conducted with 19 experienced internal medicine attendings at two Canadian universities in 2007. Attendings each discussed a specific outstanding, average, and problematic resident they had supervised. Interviews were analyzed using grounded theory. RESULTS: Eight major themes emerged reflecting how faculty conceptualize residents’ performance: knowledge, professionalism, patient interactions, team interactions, systems, disposition, trust, and impact on staff. Attendings’ impressions of residents did not seem to result from a linear sum of dimensions; rather, domains idiosyncratically took on variable degrees of importance depending on the resident. Relative deficiencies in outstanding residents could be overlooked, whereas strengths in problematic residents could be discounted. Some constructs (e.g., impact on staff) were not competencies at all; rather, they seem to act as explanations or evidence of attendings’ opinions. Standardized evaluation forms might constrain authentic depictions of residents’ performance. CONCLUSIONS: Despite concerted efforts to create standardized, objective, competency-based evaluations, the assessment of residents’ clinical performance still has a strong subjective influence. Attendings’ holistic impressions should not be considered invalid simply because they are subjective. Instead, assessment methods should consider novel ways of accommodating these impressions to improve evaluation.

PMID: 20520025 [PubMed - as supplied by publisher]

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Commentary: Health Care Technology and Medical Education: Putting Physical Diagnosis in Its Proper Place.

Acad Med. 2010 Jun;85(6):945-946

Authors: Goodman RL

Bemoaning the lost art of the physical exam is an ancient practice, dating back hundreds, if not thousands, of years. Since the introduction of the stethoscope in the early 19th century, the clinical skills of physicians have waned as their dependence on technology has grown. This “lost skills literature” reflects the ambivalent relationship the medical profession has had with its technology, a relationship also dating back centuries. Despite the dominant role played by technology in the life of the 21st-century physician, medical students and trainees do not receive sufficient formal training in its use and assessment. This lacuna in training likely contributes to the well-documented inappropriate use of health care technology that threatens any attempt at improved patient care and reform of the health care system. The author recommends the introduction of a formal curriculum in the use and assessment of health care technology in medical education and training.

PMID: 20505391 [PubMed - as supplied by publisher]

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Primary Care Specialty Choices of United States Medical Graduates, 1997-2006.

Acad Med. 2010 Jun;85(6):947-958

Authors: Jeffe DB, Whelan AJ, Andriole DA

PURPOSE: To describe trends in specialty choice and to identify predictors of primary care specialty choices among graduates of U.S. MD-granting medical schools. METHOD: A longitudinal study evaluated 1997-2006 medical school graduates who completed the Association of American Medical Colleges' Matriculating Student Questionnaire and Graduation Questionnaire. Multivariate logistic regression identified significant predictors of graduates' choice of primary care specialty (general internal medicine, general pediatrics, internal medicine subspecialties, pediatrics subspecialties, family medicine, and obstetrics-gynecology) or "no-board-certification specialty," compared with all other specialties (reference). RESULTS: The sample included 102,673 graduates (64.9% of all 1997-2006 graduates). General internal medicine, family medicine, general pediatrics, and obstetrics-gynecology choice decreased, whereas internal medicine subspecialties, pediatrics subspecialties, and no-board-certification specialty choice increased over time (each: P < .001). Female graduates and those who planned to practice in underserved communities, espoused more-altruistic beliefs about health care, and ascribed greater importance to social responsibility in their choice of medicine at matriculation were more likely to choose general internal medicine, general pediatrics, family medicine, or obstetrics-gynecology, whereas graduates who had a physician parent and who planned full-time academic medicine careers were less likely to do so (each: P < .01). Graduates with higher debt were less likely to choose internal medicine and pediatrics specialties (each: P < .001) and more likely to choose obstetrics-gynecology (P = .001). CONCLUSIONS: Generalist-primary care specialty choices declined since 1997, whereas primary care subspecialty and no-board-certification specialty choices increased. Associations between primary care specialty choices and demographic, attitudinal, and career intention variables can inform the design of interventions to address expected primary care workforce shortages.

PMID: 20505392 [PubMed - as supplied by publisher]

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Measuring the Intensity of Resident Supervision in the Department of Veterans Affairs: The Resident Supervision Index.

Acad Med. 2010 Mar 18;

Authors: Byrne JM, Kashner M, Gilman SC, Aron DC, Cannon GW, Chang BK, Godleski L, Golden RM, Henley SS, Holland GJ, Kaminetzky CP, Keitz SA, Kirsh S, Muchmore EA, Wicker AB

PURPOSE: To develop a survey instrument designed to quantify supervision by attending physicians in nonprocedural care and to assess the instrument’s feasibility and reliability. METHOD: In 2008, the Department of Veterans Affairs (VA) Office of Academic Affiliations convened an expert panel to adopt a working definition of attending supervision in nonprocedural patient care and to construct a survey to quantify it. Feasibility was field-tested on residents and their supervising attending physicians at primary care internal medicine clinics at the VA Loma Linda Healthcare System in their encounters with randomly selected outpatients diagnosed with either major depressive disorder or diabetes. The authors assessed both interrater concurrent reliability and test-retest reliability. RESULTS: The expert panel adopted the VA’s definition of resident supervision and developed the Resident Supervision Index (RSI) to measure supervision in terms of residents’ case understanding, attending physicians’ contributions to patient care through feedback to the resident, and attending physicians’ time (minutes). The RSI was field-tested on 60 residents and 37 attending physicians for 148 supervision episodes from 143 patient encounters. Consent rates were 94% for residents and 97% for attending physicians; test-retest reliability intraclass correlations (ICCs) were 0.93 and 0.88, respectively. Concurrent reliability between residents’ and attending physicians’ reported time was an ICC of 0.69. CONCLUSIONS: The RSI is a feasible and reliable measure of resident supervision that is intended for research studies in graduate medical education focusing on education outcomes, as well as studies assessing quality of care, patient health outcomes, care costs, and clinical workload.

PMID: 20305532 [PubMed - as supplied by publisher]

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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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Related Articles

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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