'It's surprising how differently they treat you': a qualitative analysis of trainee reflections on a new programme for generalist doctors

OBJECTIVES

An increase in patients with long-term conditions and complex care needs presents new challenges to healthcare providers around the developed world. In response, more broad-based training programmes have developed to better prepare trainees for the changing landscape of healthcare delivery. This paper focuses on qualitative elements of a longitudinal, mixed-methods evaluation of the postgraduate, post-Foundation Broad-Based Training (BBT) programme in England. It aims to provide a qualitative analysis of trainees' evaluations of whether the programme meets its intentions to develop practitioners adept at managing complex cases, patient focused care, specialty integration and conviction in career choice. We also identify unintended consequences.

SETTING

9 focus groups of BBT trainees were held over a 12-month period. Discussions were audio-recorded and subjected to directed content analysis. Data were collected from trainees across all 7 participating regions: East Midlands; West Midlands; Severn; Northern; North Western; Yorkshire and Humber; Kent, Surry and Sussex.

PARTICIPANTS

Focus group participants (61 in total) from the first and second cohorts of BBT.

RESULTS

Evidence from trainees indicated that the programme was meeting its aims: trainees valued the extra time to decide on their onward career specialty, having a wider experience and developing a more integrated perspective. They thought of themselves as different and perceived that others they worked alongside also saw them as different. Being different meant benefitting from novel training experiences and opportunities for self-development. However, unintended consequences were feelings of isolation, and uncertainty about professional identity.

CONCLUSIONS

By spanning boundaries between specialties, trainee generalists have the potential to improve experiences and outcomes for patients with complex health needs. However, the sense of isolation will inhibit this potential. We employ the concept of 'belongingness' to identify challenges related to the implementation of generalist training programmes within existing structures of healthcare provision.

Comparing Professional Schools and Traditional Clinical Program Faculty on Measures of Professional and Scientific Achievement

474 faculty in 56 professional clinical psychology programs were compared with 972 faculty from 157 traditional clinical psychology programs. The faculty in the professional programs were more likely to be licensed (93% to 85%) and to be diplomates of the American Board of Professional Psychology (15% to 11%, respectively). The faculty in traditional programs averaged more publications (35 vs 17) and citations, and they were more likely to be fellows of the American Psychological Association (26% to 11%). These differences appear congruent with the different missions and objectives of the two types of programs. There were no differences in the number of years since the doctorate, used as a measure of professional experience.

An orientation to wellness for new faculty of medicine members: meeting a need in faculty development

OBJECTIVES

To evaluate the format, content, and effectiveness of a newly developed orientation to wellness workshop, and to explore participants' overall perceptions.

METHODS

This was a mixed methods study. Participants consisted of 47 new faculty of medicine members who attended one of the four workshops held between 2011 and 2013. Questionnaires were used to evaluate workshop characteristics (10 survey items; response scale 1=unacceptable to 7=outstanding), intention to change behavior (yes/no), and retrospective pre/post workshop self-efficacy (4 survey items; response scale 1=no confidence to 6=absolute confidence). Mean scores and standard deviations were calculated for the workshop characteristics. Pre/post workshop self-efficacy scores were compared using a Wilcoxon signed-rank test. Participants' written qualitative feedback was coded using an inductive strategy to identify themes.

RESULTS

There was strong support for the workshop characteristics with mean scores entirely above 6.00 (N=42). Thirty-one of 34 respondents (91%) expressed intention to change their behavior as a result of participating in the workshop. The post workshop self-efficacy scores (N=38 respondents) increased significantly for all four items (p<0.0001) compared to pre workshop ratings. Participants perceived the key workshop elements as the evidence-based content relevant to academic physicians, incorporation of practical tips and strategies, and an atmosphere conducive to discussion and experience sharing.

CONCLUSIONS

  Participants welcomed wellness as a focus of faculty development. Enhancing instruction around wellness has the potential to contribute positively to the professional competency and overall functioning of faculty of medicine members.

Training students to use syringe pumps: an experimental comparison of e-learning and classroom training

The inadequate use of syringe pumps can jeopardize patient safety, and syringe pump trainings are conducted to manage this risk. A critical step in this risk management process is the learning success of trainees. In the present paper, we compared an e-learning approach with standard classroom training in learning success effectives, trainees' opinion on the trainings, and investigated the relation between technological affinity and learning success. The results showed that e-learning was as effective as classroom training but nursing students' confidence in using the pump and satisfaction with the training was decreased for e-learning compared with classroom training. We discuss the results in context of the nursing e-learning literature. Finally, we discuss the literature for risk identification, risk analysis, risk treatment, and risk monitoring and control in the context of syringe pump training and add the lessons learned from the evaluated e-learning program.

Reducing primary and secondary traumatic stress symptoms among educators by training them to deliver a resiliency program (ERASE-Stress) following the Christchurch earthquake in New Zealand

The current investigation evaluated the impact of a universal school-based resiliency intervention (ERASE-Stress) on educators who were working with elementary schoolchildren exposed to the Canterbury earthquake in New Zealand. In the context of major disasters, educators may suffer from "dual trauma"; they can experience symptoms of both primary trauma (as a result of the disaster itself) and secondary trauma (as a result of working with traumatized students). Sixty-three educators were randomly assigned to either the ERASE-Stress intervention or an alternative Managing Emergencies and Traumatic Incidents (METI) program which served as a control group. Efficacy of the program was evaluated at the end of the training as well as at 8 months follow-up. Compared with educators in the control group, those in the ERASE-Stress intervention significantly reduced their posttraumatic distress and secondary traumatization symptoms, improved their perceived level of professional self-efficacy as a helper of earthquake survivors, developed an optimistic outlook regarding their personal future and enhanced their sense of hope, and honed some of their positive coping strategies and reduced the utilization of some maladaptive coping methods. These beneficial consequences of the ERASE-Stress training make it a potentially useful tool for educators working with traumatized students in the context of major disasters. (PsycINFO Database Record

No hospital left behind? Education policy lessons for value-based payment in healthcare

Value-based payment systems have been widely implemented in healthcare in an effort to improve the quality of care. However, these programs have not broadly improved quality, and some evidence suggests that they may increase inequities in care. No Child Left Behind is a parallel effort in education to address uneven achievement and inequalities. Yet, by penalizing the lowest performers, No Child Left Behind's approach to accountability has led to a number of unintended consequences. This article draws lessons from education policy, arguing that financial incentives should be designed to support the lowest performers to improve quality.

Using Interprofessional Learning for Continuing Education: Development and Evaluation of the Graduate Certificate Program in Health Professional Education for Clinicians

INTRODUCTION

Health professionals may be expert clinicians but do not automatically make effective teachers and need educational development. In response, a team of health academics at an Australian university developed and evaluated the continuing education Graduate Certificate in Health Professional Education Program using an interprofessional learning model.

METHODS

The model was informed by Collins interactional expertise and Knowles adult learning theories. The team collaboratively developed and taught four courses in the program. Blended learning methods such as web-based learning, face-to-face workshops, and online discussion forums were used. Twenty-seven multidisciplinary participants enrolled in the inaugural program. Focus group interview, self-report questionnaires, and teacher observations were used to evaluate the program.

RESULTS

Online learning motivated participants to learn in a collaborative virtual environment. The workshops conducted in an interprofessional environment promoted knowledge sharing and helped participants to better understand other discipline roles, so they could conduct clinical education within a broader health care team context. Work-integrated assessments supported learning relevance. The teachers, however, observed that some participants struggled because of lack of computer skills.

DISCUSSION

Although the interprofessional learning model promoted collaboration and flexibility, it is important to note that consideration be given to participants who are not computer literate. We therefore conducted a library and computer literacy workshop in orientation week which helped. An interprofessional learning environment can assist health professionals to operate outside their "traditional silos" leading to a more collaborative approach to the provision of care. Our experience may assist other organizations in developing similar programs.

A Flipped Classroom Approach to Improving the Quality of Delirium Care Using an Interprofessional Train-the-Trainer Program

INTRODUCTION

Given the prevalence and morbidity associated with delirium, there is a need for effective and efficient institutional approaches to delirium training in health care settings. Novel education methods, specifically the "flipped classroom" (FC) and "train-the-trainer" (TTT), have the potential to address these delirium training gaps. This study evaluates the effect of a TTT FC interprofessional delirium training program on participants' perceived ability to manage delirium, delirium knowledge, and clinicians' delirium assessment behaviors.

METHODS

FC Delirium TTT sessions were implemented in a large four-hospital network and consisted of presession online work and a 3-hour in-session component. The 156 TTT interprofessional participants who attended the sessions (ie, trainers) were expected to then deliver delirium training to their patient care units. Delirium care self-efficacy and knowledge test scores were measured before, after, and 6 months after the training session. Clinician delirium assessment rates were measured by chart audits before and 3 months after trainer's implementation of delirium training sessions.

RESULTS

Delirium knowledge test scores (7.8 ± 1.6 versus 9.7 ± 1.2, P < .001) and delirium care self-efficacy were significantly higher immediately after the TTT session compared with those of presession and these differences remained significant at 6-month after the TTT session. Trainer sessions significantly improved clinician delirium assessment rates from 53% for pretraining to 66% for posttraining.

DISCUSSION

Our data suggest that a TTT FC delirium training approach can improve participants' perceived delirium care skills and confidence, and delirium knowledge up to 6 months after the session. This approach provides a model for implementing hospitalwide delirium education that can change delirium assessment behavior while minimizing time and personnel requirements.

Inadequacy of Palliative Training in the Medical School Curriculum

This report examines the literature on palliative training in the current medical school curriculum. A literature search was conducted to identify relevant articles. Physicians and medical students both report feeling that their training in end-of-life care and in palliative issues is lacking. The literature expresses concerns about the varied and non-uniform approach to palliative care training across medical schools. The authors recommend the development of more palliative training assessment tools in order to aid in the standardization of curriculum involving end-of-life care. In addition, increased exposure to dying patients will aid students in building comfort with palliative care issues. Such a goal may be accomplished through required clerkships or other similar programs.

Global health leadership training in resource-limited settings: a collaborative approach by academic institutions and local health care programs in Uganda

INTRODUCTION

Due to a limited health workforce, many health care providers in Africa must take on health leadership roles with minimal formal training in leadership. Hence, the need to equip health care providers with practical skills required to lead high-impact health care programs. In Uganda, the Afya Bora Global Health Leadership Fellowship is implemented through the Makerere University College of Health Sciences (MakCHS) and her partner institutions. Lessons learned from the program, presented in this paper, may guide development of in-service training opportunities to enhance leadership skills of health workers in resource-limited settings.

METHODS

The Afya Bora Consortium, a consortium of four African and four U.S. academic institutions, offers 1-year global health leadership-training opportunities for nurses and doctors. Applications are received and vetted internationally by members of the consortium institutions in Botswana, Kenya, Tanzania, Uganda, and the USA. Fellows have 3 months of didactic modules and 9 months of mentored field attachment with 80% time dedicated to fellowship activities. Fellows' projects and experiences, documented during weekly mentor-fellow meetings and monthly mentoring team meetings, were compiled and analyzed manually using pre-determined themes to assess the effect of the program on fellows' daily leadership opportunities.

RESULTS

Between January 2011 and January 2015, 15 Ugandan fellows (nine doctors and six nurses) participated in the program. Each fellow received 8 weeks of didactic modules held at one of the African partner institutions and three online modules to enhance fellows' foundation in leadership, communication, monitoring and evaluation, health informatics, research methodology, grant writing, implementation science, and responsible conduct of research. In addition, fellows embarked on innovative projects that covered a wide spectrum of global health challenges including critical analysis of policy formulation and review processes, bottlenecks in implementation of national HIV early infant diagnosis and prevention of mother-to-child HIV-transmission programs, and use of routine laboratory data about antibiotic resistance to guide updates of essential drug lists.

CONCLUSION

In-service leadership training was feasible, with ensured protected time for fellows to generate evidence-based solutions to challenges within their work environment. With structured mentorship, collaborative activities at academic institutions and local health care programs equipped health care providers with leadership skills.

Equality and quality in education. A comparative study of 19 countries

This contribution assesses the performance of national education systems along two important dimensions: The degree to which they help individuals develop capabilities necessary for their successful social integration (educational quality) and the degree to which they confer equal opportunities for social advancement (educational equality). It advances a new conceptualization to measure quality and equality in education and then uses it to study the relationship between institutional differentiation and these outcomes. It relies on data on final educational credentials and literacy among adults that circumvent some of the under-appreciated conceptual challenges entailed in the widespread analysis of international student assessment data. The analyses reveal a positive relationship between educational quality and equality and show that education systems with a lower degree of institutional differentiation not only provide more educational equality but are also marked by higher levels of educational quality. While the latter association is partly driven by other institutional and macro-structural factors, I demonstrate that the higher levels of educational equality in less differentiated education systems do not entail an often-assumed trade-off for lower quality.

Academician Attitudes and Beliefs Regarding the Use of Hospitalists: A CERA Study

BACKGROUND AND OBJECTIVES

The hospitalist model of inpatient care has spread into many hospitals in the United States with over 34,000 physicians, mostly general internists. Less than 4% of hospitalists trained as family doctors. Around 60% of family medicine residency programs (FMRPs) use hospitalists in their teaching model. Despite the swift growth of hospitalists, there are no reports as to medical educators' beliefs regarding hospitalists. The objective of this project was to survey FMRP directors regarding their attitudes and beliefs concerning the hospitalist model. This paper also reports on numbers of recent FMRP graduates entering hospitalist positions.

METHODS

All US allopathic FMRP directors were surveyed in October 2013. The survey questions were part of a larger CERA omnibus survey.

RESULTS

The response rate was 56.4%. Of 2012/2013 family medicine graduates, 9.2% entered hospitalist positions. FMRPs in the Southern United States, or of the community-based non-affiliated program type, as well as programs with higher percentages of current residents who are international medical graduates produce the most hospitalists. Most program directors did not feel their residents needed different hospital skills training than they are currently being taught. Use of hospitalists was not felt to improve patient care nor interfere with FMRPs influence at their teaching hospital.

CONCLUSIONS

Program directors generally felt neutral or positive about hospitalists and did not think this care model had positively or adversely affected their programs. Many family medicine residents are entering hospitalist positions upon graduating. Family medicine as a discipline should continue to study the hospitalist care model and its impact on family medicine training.

The Predictive Validity of the ABFM's In-Training Examination

BACKGROUND AND OBJECTIVES

Our objective was to examine the predictive validity of the American Board of Family Medicine's (ABFM) In-Training Examination (ITE) with regard to predicting outcomes on the ABFM certification examination.

METHODS

This study used a repeated measures design across three levels of medical training (PGY1--PGY2, PGY2--PGY3, and PGY3--initial certification) with three different cohorts (2010--2011, 2011--2012, and 2012--2013) to examine: (1) how well the residents' ITE scores correlated with their test scores in the following year, (2) what the typical score increase was across training years, and (3) what was the sensitivity, specificity, positive predictive value, and negative predictive value of the PGY3 scores with regard to predicting future results on the MC-FP Examination.

RESULTS

ITE scores generally correlate at about .7 with the following year's ITE or with the following year's certification examination. The mean growth from PGY1 to PGY2 was 52 points, from PGY2 to PGY3 was 34 points, and from PGY3 to initial certification was 27 points. The sensitivity, specificity, positive predictive value, and negative predictive value were .91, .47, .96, and .27, respectively.

CONCLUSION

The ITE is a useful predictor of future ITE and initial certification examination performance.

The new milestones: do we need to take a step back to go a mile forward?

The Milestones Project, like all previous systems and changes in graduate psychiatric education, for example, moving from 3 to 4 years of training or adopting six competency domains, has been devised without any supporting data and does not assess meaningful outcomes, such as improved patient outcomes. No evidence is presented that Milestones-based training will produce better psychiatrists. There is a path forward. First, replace unproven expert consensus with scientific and evidence-based approaches. Second, exchange endpoints that are easy to assess but uncorrelated with real world functioning (e.g., multiple-choice examinations) for outcomes that are meaningful and external to the training program (e.g., patient outcomes). Finally, to prevent possible waste, excess burden, or harm, no changes should be mandated until proven in prospective studies.

The development of education indicators for measuring quality in the English-speaking Caribbean: how far have we come?

Education evaluation has become increasingly important in the English-speaking Caribbean. This has been in response to assessing the progress of four regional initiatives aimed at improving the equity, efficiency, and quality of education. Both special interest groups and local evaluators have been responsible for assessing the progress of education and providing an overall synthesis and summary of what is taking place in the English-speaking Caribbean. This study employed content analysis to examine the indicators used in these education evaluation studies since the declaration of the Caribbean Plan of Action 2000-2015 to determine these indicators' appropriateness to the Caribbean context in measuring education progress. Findings demonstrate that the English-speaking Caribbean has made strides in operationalizing quality input, process, and output indicators; however quality outcome indicators beyond test scores are yet to be realized in a systematic manner. This study also compared the types of collaborative partnerships in conducting evaluation studies used by special interest groups and local evaluators and pinpointed the one that appears most suitable for special interest groups in this region.

The role of education in explaining racial/ethnic allostatic load differentials in the United States

This study expands on earlier findings of racial/ethnic and education-allostatic load associations by assessing whether racial/ethnic differences in allostatic load persist across all levels of educational attainment. This study used data from four recent waves of the National Health and Nutrition Survey (NHANES). Results from this study suggest that allostatic load differs significantly by race/ethnicity and educational attainment overall, but that the race/ethnicity association is not consistent across education level. Analysis of interactions and education-stratified models suggest that allostatic load levels do not differ by race/ethnicity for individuals with low education; rather, the largest allostatic load differentials for Mexican Americans (p < .01) and non-Hispanic blacks (p < .001) are observed for individuals with a college degree or more. These findings add to the growing evidence that differences in socioeconomic opportunities by race/ethnicity are likely a consequence of differential returns to education, which contribute to higher stress burdens among minorities compared to non-Hispanic whites.

College quality and hourly wages: evidence from the self-revelation model, sibling models and instrumental variables

This paper addresses the recent discussion on confounding in the returns to college quality literature using the Norwegian case. The main advantage of studying Norway is the quality of the data. Norwegian administrative data provide information on college applications, family relations and a rich set of control variables for all Norwegian citizens applying to college between 1997 and 2004 (N = 141,319) and their succeeding wages between 2003 and 2010 (676,079 person-year observations). With these data, this paper uses a subset of the models that have rendered mixed findings in the literature in order to investigate to what extent confounding biases the returns to college quality. I compare estimates obtained using standard regression models to estimates obtained using the self-revelation model of Dale and Krueger (2002), a sibling fixed effects model and the instrumental variable model used by Long (2008). Using these methods, I consistently find increasing returns to college quality over the course of students' work careers, with positive returns only later in students' work careers. I conclude that the standard regression estimate provides a reasonable estimate of the returns to college quality.

US dermatology residency program rankings

Unlike many other adult specialties, US News & World Report does not rank dermatology residency programs annually. We conducted a study to rank individual US dermatology residency programs based on set criteria. For each residency program, data from 2008 related to a number of factors were collected, including annual amount of National Institutes of Health (NIH) and Dermatology Foundation (DF) funding received; number of publications from full-time faculty members; number of faculty lectures given at 5 annual society meetings; and number of full-time faculty members who were on the editorial boards of 6 dermatology journals with the highest impact factors. Most of the data were obtained through extensive Internet searches, and missing data were obtained by contacting individual residency programs. The programs were ranked based on the prior factors according to a weighted ranking algorithm. A list of overall rankings also was created.