Commentary: faculty development: the road less traveled.

Acad Med. 2011 Apr;86(4):409-11

Authors: Steinert Y

Abstract
The 2020 Vision of Faculty Development Across the Medical Education Continuum conference, and the resulting articles in this issue, addressed a number of topics related to the future of faculty development. Focusing primarily on the development of faculty members as teachers, conference participants debated issues related to core teaching competencies, barriers to effective teaching, competency-based assessment, relationship-centered care, the hidden curriculum that faculty members encounter, instructional technologies, continuing medical education, and research on faculty development. However, a number of subjects were not addressed. If faculty development is meant to play a leading role in ensuring that academic medicine remains responsive to faculty members and societal needs, additional themes should be considered. Medical educators should broaden the focus of faculty development and target the various roles that clinicians and basic scientists play, including those of leader and scholar. They must also remember that faculty development can play a critical role in curricular and organizational change and thus enlarge the scope of faculty development by moving beyond formal, structured activities, incorporating notions of self-directed learning, peer mentoring, and work-based learning. In addition, medical educators should try to situate faculty development in a more global context and collaborate with international colleagues in the transformation of medical education and health care delivery. It has been said that faculty development can play a critical role in promoting culture change at a number of levels. A broader mandate, innovative programming that takes advantage of communities of practice, and new partnerships can help to achieve this objective.

PMID: 21451270 [PubMed - indexed for MEDLINE]

The essential value of projects in faculty development.

Acad Med. 2010 Sep;85(9):1484-91

Authors: Gusic ME, Milner RJ, Tisdell EJ, Taylor EW, Quillen DA, Thorndyke LE

Abstract
Projects--planned activities with specific goals and outcomes--have been used in faculty development programs to enhance participant learning and development. Projects have been employed most extensively in programs designed to develop faculty as educators. The authors review the literature and report the results of their 2008 study of the impact of projects within the Pennsylvania State University College of Medicine Junior Faculty Development Program, a comprehensive faculty development program. Using a mixed-methods approach, the products of project work, the academic productivity of program graduates, and the impact of projects on career development were analyzed. Faculty who achieved the most progress on their projects reported the highest number of academic products related to their project and the highest number of overall academic achievements. Faculty perceived that their project had three major effects on their professional development: production of a tangible outcome, development of a career focus, and development of relationships with mentors and peers. On the basis of these findings and a review of the literature, the authors conclude that projects are an essential element of a faculty development program. Projects provide a foundation for future academic success by enabling junior faculty to develop and hone knowledge and skills, identify a career focus and gain recognition within their community, generate scholarship, allocate time to academic work, and establish supportive relationships and collaborative networks. A list of best practices to successfully incorporate projects within faculty development programs is provided.

PMID: 20671538 [PubMed - indexed for MEDLINE]

Exploring Error in Team-Based Acute Care Scenarios: An Observational Study From the United Kingdom.

Acad Med. 2012 Apr 24;

Authors: Tallentire VR, Smith SE, Skinner J, Cameron HS

Abstract
PURPOSE: To investigate the errors made by junior doctors (first year after primary medical qualification) in simulated acute care settings, using (and, for some purposes, amplifying) a previously published generic error-modeling system (GEMS). Possible error types were skill-based slips and lapses, rule-based mistakes, knowledge-based mistakes, and violations. METHOD: In August 2010, 38 junior doctors participated in high-fidelity simulated acute care scenarios in NHS Lothian, Scotland. Each video-recorded scenario was immediately followed by an audio-recorded debrief that encouraged articulation of underlying cognitive processes. Two researchers used evidence from the scenario, debrief, and field notes to determine which errors were attributable to a single underlying cause. In such cases, the errors were coded by template analysis into the GEMS framework. Errors for which a single cause could be identified but which did not fit the framework were coded inductively. RESULTS: A total of 243 errors were identified, with sufficient evidence available to identify a single cause in 190. Skill-based slips and lapses, rule-based mistakes, and knowledge-based mistakes were all clearly identified within the data. Two error types not originally included in the GEMS framework were identified: compound errors and submission errors. CONCLUSIONS: Amplification of GEMS provides a valid framework for categorization of the errors made by junior doctors in simulated acute care contexts. In addition, the amplified framework may be transferable to other, team-based contexts. An improved understanding of the knowledge and skills that are most vulnerable to each specific type of error will allow tailored educational strategies to be developed.

PMID: 22534595 [PubMed - as supplied by publisher]

An Educational Intervention to Improve Cost-Effective Care Among Medicine Housestaff: A Randomized Controlled Trial.

Acad Med. 2012 Apr 24;

Authors: Sommers BD, Desai N, Fiskio J, Licurse A, Thorndike M, Katz JT, Bates DW

Abstract
PURPOSE: High medical costs create significant burdens. Research indicates that doctors have little awareness of costs. This study tested whether a brief educational intervention could increase residents' awareness of cost-effectiveness and reduce costs without negatively affecting patient outcomes. METHOD: The authors conducted a clustered randomized controlled trial of 33 teams (96 residents) at an internal medicine residency program (2009-2010). The intervention was a 45-minute teaching session; residents reviewed the hospital bill of a patient for whom they had cared and discussed reducing unnecessary costs. Primary outcomes were laboratory, pharmacy, radiology, and total hospital costs per admission. Secondary measures were length of stay (LOS), intensive care unit (ICU) admission, 30-day readmission, and 30-day mortality. Multivariate adjustment controlled for patient demographics and health. A follow-up survey assessed resident attitudes three months later. RESULTS: Among 1,194 patients, there were no significant cost differences between intervention and control groups. In the intervention group, 30-day readmission was higher (adjusted odds ratio 1.51, P = .010). There was no effect on LOS or the composite outcome of readmission, mortality, and ICU transfer. In a subgroup analysis of 835 patients newly admitted during the study, the intervention group incurred $163 lower adjusted lab costs per admission (P = .046). The follow-up survey indicated persistent differences in residents' exposure to concepts of cost-effectiveness (P = .041). CONCLUSIONS: A brief intervention featuring a discussion of hospital bills can fill a gap in resident education and reduce laboratory costs for a subset of patients, but may increase readmission risk.

PMID: 22534589 [PubMed - as supplied by publisher]

Contemporary Performance of U.S. Teaching and Nonteaching Hospitals.

Acad Med. 2012 Apr 24;

Authors: Shahian DM, Nordberg P, Meyer GS, Blanchfield BB, Mort EA, Torchiana DF, Normand SL

Abstract
PURPOSE: To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics. METHOD: The authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or Council of Teaching Hospitals member. They compared aggregate results across categories for Hospital Compare process compliance, mortality, and readmission rates (acute myocardial infarction [AMI], heart failure, pneumonia); Surgical Care Improvement Project (SCIP) performance; compliance with Leapfrog standards; patient experience; patient services and key technologies; safety (computerized physician order entry, intensive care unit staffing, National Quality Forum safe practices, hospital-acquired conditions); and cost/resource utilization (Medicare-adjusted expense per case; Leapfrog efficiency and resource use standards). RESULTS: Availability of patient services and advanced technologies were associated with teaching intensity (P < .0001), as were most hospital safety metrics. Teaching intensity was favorably associated with SCIP performance, AMI and heart failure process scores, and mortality (P < .0001). It was unfavorably associated with higher AMI and pneumonia readmission rates (P < .0001) and lower scores for individual patient satisfaction measures. Costs per case were similar (P = .4194) across hospital categories after correction for federally allowed adjustments (case mix, wages, and low-income patient care). CONCLUSIONS: Teaching hospitals offer advanced clinical capabilities, educate the next generation of providers, care for disadvantaged urban populations, and are leaders in health care research and innovation. However, many stakeholders may be unaware of an additional value-relatively higher quality and safety in many areas, with similar adjusted costs.

PMID: 22534588 [PubMed - as supplied by publisher]

The Rise and Fall of the American Jewish Hospital.

Acad Med. 2012 Mar 23;

Authors: Halperin EC

Abstract
American Jewish hospitals were founded, starting in 1854, to serve indigent Jews, to respond to anti-Semitism by creating opportunities for graduate medical education (GME) and medical practice, to provide culturally sensitive care to observant Jews, and to fulfill a religious commitment to healing. Jewish hospitals were governed, administered, staffed, and philanthropically supported predominantly by Jewish communities.In this essay, the author describes the origins of American Jewish hospitals, the purposes they were designed to serve, and why they are disappearing. He estimates that approximately 113 Jewish hospitals were founded in the history of the United States and that there are now about 22 left, some of which are Jewish in name only. Jewish hospitals have been disappearing as a result of the economic pressures facing all community hospitals, a decline in anti-Semitism, open access to GME positions and hospital privileges, the general acceptance of Jews in the American mainstream, and a loss of Jewish community philanthropy.

PMID: 22450187 [PubMed - as supplied by publisher]

Perspective: Resident Physician Wellness: A New Hope.

Acad Med. 2012 Mar 23;

Authors: Lefebvre DC

Abstract
Residency training is a challenging period in a physician's career owing to a multitude of stressors perhaps not previously encountered. In some cases, these stressors may culminate in a state of burnout. In response, much has been written about the issues of personal wellness during residency training. Recently, duty hours reform has been the major focus of addressing resident wellness; however, this intervention has established little benefit and has created unintended negative consequences. Alternatively, an emerging solution may be the implementation of resident wellness programs into residency training. Such programs are defined by a combination of active and passive initiatives targeting the various domains of physical, mental, social, and intellectual wellness. In contrast to duty hours reform, resident wellness programs are generally free from controversy and have been shown to improve resident wellness and enhance empathy.This article highlights the salient causes of burnout as it applies to present-day resident physicians and the patient care they provide. Moreover, in the wake of the controversy surrounding duty hours reform, a novel approach to resident wellness involving structured resident wellness programs is discussed. Specifically included are the fundamental components of a wellness program, the advantages held over duty hours reform, methods to evaluate program efficacy, and the current evidence to support these initiatives. Formal wellness curricula, including an evaluative process, should be an integral component of physician training. These programs represent a new hope in the solution to the long-debated issue of burnout and wellness during residency training.

PMID: 22450179 [PubMed - as supplied by publisher]

Commentary: time to sign off on signout.

Acad Med. 2011 Jul;86(7):804-6

Authors: Stein DM, Stetson PD

Abstract
The physician signout note is a widely used clinical document that supports patient safety and care continuity during patient handoff in the hospital. Despite its centrality to patient care, the signout note is not considered an official document, and it is, therefore, not generally standardized or taught to medical trainees, nor is it usually integrated into electronic health records (EHRs). This commentary outlines several of the potential advantages to establishing the physician signout note as an official part of the medical record, such as the facilitation of information flow between signout notes and other parts of the patient chart and the possibility of integrating decision support tools into this important aspect of the clinical workflow. The authors address frequently encountered concerns regarding the establishment of the signout note as an official part of the medical record. They conclude by making recommendations for integrating signout notes into EHRs and using modern, social Web technologies in such an implementation.

PMID: 21715993 [PubMed - indexed for MEDLINE]

Developing Expert-Derived Rating Standards for the Peer Assessment of Lectures.

Acad Med. 2012 Jan 26;

Authors: Newman LR, Brodsky DD, Roberts DH, Pelletier SR, Johansson A, Vollmer CM, Atkins KM, Schwartzstein RM

Abstract
PURPOSE: For peer review of teaching to be credible and reliable, peer raters must be trained to identify and measure teaching behaviors accurately. Peer rater training, therefore, must be based on expert-derived rating standards of teaching performance. The authors sought to establish precise lecture rating standards for use in peer rater training at their school. METHOD: From 2008 to 2010, a panel of experts, who had previously helped to develop an instrument for the peer assessment of lecturing, met to observe, discuss, and rate 40 lectures, using a consensus-building model to determine key behaviors and levels of proficiency for each of the instrument's 11 criteria. During this process, the panelists supplemented the original instrument with precise behavioral descriptors of lecturing. The reliability of the derived rating standards was assessed by having the panelists score six sample lectures independently. RESULTS: Intraclass correlation coefficients of the panelists' ratings of the lectures ranged from 0.75 to 0.96. There was moderate to high positive association between 10 of the 11 instrument's criteria and the overall performance score (r = 0.752-0.886). There were no statistically significant differences among raters in terms of leniency or stringency of scores. CONCLUSIONS: Two relational themes, content and style, were identified within the instrument's variables. Recommendations for developing expert-derived ratings standards include using an interdisciplinary group for observation, discussion, and verbal identification of behaviors; asking members to consider views that contrast with their own; and noting key teaching behaviors for use in future peer rater training.

PMID: 22281550 [PubMed - as supplied by publisher]

Patient safety stories: a project utilizing narratives in resident training.

Acad Med. 2011 Nov;86(11):1473-8

Authors: Cox LM, Logio LS

Abstract
Incident reports have traditionally been the vehicle for identifying, assessing, and responding to quality gaps in hospitals. Yet because of a variety of barriers, residents often fail to participate in this formal process. The authors created a project to engage residents in incident reporting through the use of an online, anonymous narrative format, faculty-facilitated discussion groups, and involvement of patient safety officers in the educational process. During three months, 36 residents submitted a total of 79 stories about patient care that did not "go as intended." The authors reviewed and scored each story for contributing factors and outcomes. The residents met monthly in small groups with trained faculty facilitators to analyze the stories, which were also shared with the patient safety officers. The stories, narratives of both personal involvement and observed events, ranged from near-misses to sentinel events. Key contributing factors included lapses of professionalism, decision errors, communication/information mishaps, transition mix-ups, and workload difficulties. The narrative format proved a feasible tool for collecting significant, previously unrecognized patient safety issues. Internal medicine residents were willing to discuss gaps in care when given the tools and opportunity for anonymous storytelling and blame-free dialogue.

PMID: 21952066 [PubMed - indexed for MEDLINE]

Relating Faults in Diagnostic Reasoning With Diagnostic Errors and Patient Harm.

Acad Med. 2011 Dec 20;

Authors: Zwaan L, Thijs A, Wagner C, van der Wal G, Timmermans DR

Abstract
PURPOSE: The relationship between faults in diagnostic reasoning, diagnostic errors, and patient harm has hardly been studied. This study examined suboptimal cognitive acts (SCAs; i.e., faults in diagnostic reasoning), related them to the occurrence of diagnostic errors and patient harm, and studied the causes. METHOD: Four expert internists reviewed patient records of 247 dyspnea patients, using a specially developed questionnaire to detect SCAs. The patients were treated by 72 physicians between May 2007 and February 2008 in five Dutch hospitals. The findings of the record review were discussed with the treating physicians, and the causes of SCAs were classified using Reason's taxonomy of unsafe acts. Statistical analyses were performed with descriptive statistics and independent t tests to compare groups. Furthermore, a reliability study was conducted to assess the interrater reliability. RESULTS: SCAs occurred in 163 of 247 cases reviewed (66%). In 34 (13.8%) of all cases, a diagnostic error occurred, and in 28 (11.3%) cases, the patient was harmed. Cases with diagnostic errors or patient harm had more SCAs. However, in 10 (4.0%) of the cases, diagnostic errors or patient harm occurred, though there were no SCAs. The causes of SCAs were mostly mistakes (i.e., the planned action was incorrect). CONCLUSIONS: In cases with more SCAs, diagnostic errors and patient harm occurred more often, suggesting that the number of SCAs per case was predictive of the occurrence of these events. The most common causes were mistakes, meaning that physicians did not realize their actions were incorrect.

PMID: 22189886 [PubMed - as supplied by publisher]

Involving Clinical Librarians at the Point of Care: Results of a Controlled Intervention.

Acad Med. 2011 Oct 25;

Authors: Aitken EM, Powelson SE, Reaume RD, Ghali WA

Abstract
PURPOSE: To measure the effect of including a clinical librarian in the health care team on medical residents and clinical clerks. METHOD: In 2009, medical residents and clinical clerks were preassigned to one of two patient care teams (intervention and control). Each team had a month-long rotation on the general medicine teaching unit. The clinical librarian joined the intervention team for morning intake, clinical rounding, or an afternoon patient list review, providing immediate literature searches, formal group instruction, informal bedside teaching, and/or individual mentoring for use of preappraised resources and evidence-based medicine search techniques. Both intervention and control teams completed pre and post surveys comparing their confidence levels and awareness of resources as well as their self-reported use of evidence for making patient care decisions. The nonintervention team was surveyed as the control group. RESULTS: The clinical librarian intervention had a significant positive effect on medical trainees' self-reported ability to independently locate and evaluate evidence resources to support patient care decisions. Notably, 30 of 34 (88%) reported having changed a treatment plan based on skills taught by the clinical librarian, and 27 of 34 (79%) changed a treatment plan based on the librarian's mediated search support. CONCLUSIONS: Clinical librarians on the care team led to positive effects on self-reported provider attitudes, provider information retrieval tendencies, and, notably, clinical decision making. Future research should evaluate economic effects of widespread implementation of on-site clinical librarians.

PMID: 22030761 [PubMed - as supplied by publisher]

Can Eliminating Risk Stratification Improve Medical Residents' Adherence to Venous Thromboembolism Prophylaxis?

Acad Med. 2011 Oct 25;

Authors: Polich AL, Etherton GM, Knezevich JT, Rousek JB, Masek CM, Hallbeck MS

Abstract
PURPOSE: Hospital-acquired venous thromboembolism (VTE) is a common and preventable adverse event that most patients are at risk of developing during their hospital stay. VTE prophylactic anticoagulation (chemoprophylaxis) is the preferred pharmacological assignment for reducing risk of VTE, but it is underused in current practices involving risk stratification (RS) for VTE prevention. The purpose of this study was to determine whether a protocol that eliminates the RS step (non-RS protocol) is more likely to lead residents to evidence-based VTE assignment than the currently used RS protocol. The non-RS protocol follows a methodology that reduces complexity by assuming that the risk of VTE is present and uses contraindications to determine appropriate VTE assignment. METHOD: In 2009, 41 medicine residents at the Nebraska Western Iowa Veterans Affairs clinic participated in an online comparison of two different protocols (RS and non-RS) for assigning chemoprophylaxis for VTE. Six validated, hypothetical patient scenarios were used to compare appropriate (evidence-based) VTE assignments for VTE and completion times for each protocol. RESULTS: Statistical analyses found that the non-RS protocol produced significantly faster (P < .001) scenario completion times and significantly more (P < .001) appropriate VTE assignments than the RS protocol for four of the six patient scenarios. CONCLUSIONS: This study used a new, streamlined protocol (non-RS), which improved VTE assignment and the use of chemoprophylaxis and simplified the process when compared with the use of a traditional RS protocol.

PMID: 22030760 [PubMed - as supplied by publisher]

Restructuring an Inpatient Resident Service to Improve Outcomes for Residents, Students, and Patients.

Acad Med. 2011 Oct 25;

Authors: O?connor AB, Lang VJ, Bordley DR

Abstract
PURPOSE: This study assesses the effects of a resident teaching service restructuring on resident, student, and patient outcomes. METHOD: Interventions included eliminating a "day float" admitting team, converting one-resident:one-intern teams to one-resident:two-intern teams, reducing patient caps from 11 to 7 patients per intern, and increasing pairing between resident teams and attendings. Resident end-of-rotation evaluations and time spent in categorized activities; student end-of-clerkship evaluations, patient logs, and subject exam scores; and hospital-collected patient outcome data were compared before (2007-2008) versus after (2008-2009) the changes. RESULTS: Interns covered fewer patients per day post intervention (9.9 apiece to 6.3 apiece), whereas the total number of patients covered increased (2,501 to 2,916). Enjoyment of the rotation was higher post intervention for interns and senior residents. Residents' time in direct patient care activities and with interns increased post intervention, but residents spent less time with medical students.Students' ratings of several aspects of the clerkship were significantly higher in the postintervention year. Students evaluated more previously unevaluated patients post intervention (32.6% to 45.8%, P < .001), but subject exam scores were unchanged.The median length of stay decreased post intervention (5.0 to 4.0 days, P = .02), and fewer patients required ICU care (11.2% to 7.9%, P < .001). These differences persisted after adjusting for multiple covariates. CONCLUSIONS: An intervention that reduced handoffs and intern patient census and that increased hospitalist pairing was associated with improved resident and student experiences, a favorable impact on patient outcomes, and probable cost savings.

PMID: 22030755 [PubMed - as supplied by publisher]

The Effect of Patient Feedback on Physicians' Consultation Skills: A Systematic Review.

Acad Med. 2011 Sep 26;

Authors: Reinders ME, Ryan BL, Blankenstein AH, van der Horst HE, Stewart MA, van Marwijk HW

Abstract
PURPOSE: The effect of patient feedback interventions as a method of improving physicians' consultation (i.e., communication, interpersonal) skills is equivocal; research is scarce, and methods and rigor vary. The authors conducted this systematic review to analyze the educational effect of feedback from real patients on physicians' consultation skills at the four Kirkpatrick levels. METHOD: The authors searched five databases (PubMed, EMBASE, Cochrane, PsycInfo, ERIC; April 2010). They included empirical studies of all designs (randomized controlled, quasi-experimental, cross-sectional, and qualitative) if the studies concerned physicians in general health care who received formal feedback regarding their consultation skills from real patients. The authors have briefly described aspects of the included studies, analyzed their quality, and examined their results by Kirkpatrick educational effect level. RESULTS: The authors identified 15 studies (10 studies in primary care; 5 in other specialties) in which physicians received feedback in various ways (e.g., aggregated patient reports or educator-mediated coaching sessions), conducted in the United States, the Netherlands, the United Kingdom, Australia, and Canada. All studies that assessed level 1 (valuation), level 2 (learning), and level 3 (intended behavior) demonstrated positive results; however, only four of the seven studies that assessed level 4 (change in actual performance or results) found a beneficial effect. CONCLUSIONS: Some evidence for the effectiveness of using feedback from real patients to improve knowledge and behavior exists; however, before implementing patient feedback into training programs, educators and policy makers should realize that the evidence for effecting actual improvement in physicians' consulting skills is rather limited.

PMID: 21952067 [PubMed - as supplied by publisher]