Internal Medicine Residents' Perceptions of Team-Based Care and its Educational Value in the Continuity Clinic: A Qualitative Study

Facilitators and barriers to conducting an efficient, competent and high-quality oncological multidisciplinary team meeting

BACKGROUND

Optimal oncological care nowadays requires discussing every patient in a multidisciplinary team meeting (MDTM). The number of patients to be discussed is rising rapidly due to the increasing incidence and prevalence of cancer and the emergence of new multidisciplinary treatment options. This puts MDTMs under considerable time pressure. The aim of this study is therefore to identify the facilitators and barriers with regard to performing an efficient, competent and high-quality MDTM.

METHODS

Semistructured interviews were conducted with Dutch medical specialists and residents participating in oncological MDTMs. Purposive sampling was used to maximise variation in participants' professional and demographic characteristics (eg, sex, medical specialist vs resident, specialty, type and location of affiliated hospital). Interview data were systematically analysed according to the principles of thematic content analysis.

RESULTS

Sixteen medical specialists and 19 residents were interviewed. All interviewees agreed that attending and preparing MDTMs is time-consuming and indicated the need for optimal execution in order to ensure that MDTMs remain feasible in the near future. Four themes emerged that are relevant to achieving an optimal MDTM: (1) organisational aspects; (2) participants' responsibilities and requirements; (3) competences, behaviour and team dynamics and (4) meeting content. Good organisation, a sound structure and functioning information and communication technology facilitate high-quality MDTMs. Multidisciplinary collaboration and adequate communication are essential competences for participants; a lack thereof and the existence of a hierarchy are hindering factors.

CONCLUSION

Conducting an efficient, competent and high-quality oncological MDTM is facilitated and hindered by many factors. Being aware of these factors provides opportunities for optimising MDTMs, which are under pressure due to the increase in the number of patients to discuss.

Exploring the experiences of the team members in the interprofessional socialization process for becoming a interprofessional Collaborator

BACKGROUND

The current study aimed to explore the team members' experiences in the socialization process for becoming a collaborator in an interprofessional team.

METHOD

This qualitative study is conducted using an inductive qualitative content analysis approach. Participants consisted of 32 physicians (n = 16) and nurses (n = 16) who participated by purposeful sampling. Data were collected through in-depth semi-structured interviews and analyzed by Graneheim and Lundman approach.

RESULTS

In the study, "the perceived confrontation between interprofessional professionalism and uni-professionalism in the interprofessional socialization process" is explored as the theme, including two categories: "interprofessional professionalism commitment" as a facilitator and "uni-professional centrism" as a barrier.

CONCLUSION

A reciprocal dimension in interprofessional socialization was explored. Interprofessional professionalism adherence and team-centered accountability among team members were explored as a facilitator. The uni-professional culture and immature interprofessional collaboration competencies of team members disrupted the interprofessional socialization process.

Interprofessional education in the clinical learning environment: a mixed-methods evaluation of a longitudinal experience in the primary care setting

Team collaboration in our healthcare workforce is necessary to effectively address multifaceted medical and social needs, especially for those impacted by systemic inequities. Effective interprofessional practice and education models including curricula are needed to prepare a practice ready healthcare workforce for team collaboration. Most healthcare trainee interprofessional experiences take place episodically in classroom settings. However, creating a culture that supports team-based learning and interprofessional clinical practice requires teaching skills (e.g., communication, collaboration, shared decision-making, coordination of care) longitudinally in the clinical setting. A weekly interprofessional clinic for patients/clients with chronic health conditions was organized in three primary care practices. Trainees from nutrition, social work, medicine, and physician assistant programs worked with supervising clinicians from each field. Surveys, interviews, and focus groups assessed the effects of interprofessional education and training in the primary care setting. Results show the longitudinal experiential IPE program significantly improved knowledge, attitudes, skills, and values addressing key interprofessional competencies. Qualitative results complement survey data and highlight key themes addressing patient-centered care and team dynamics. These findings demonstrate the importance of longitudinal, immersive team-based interprofessional training in the clinical learning environment.

Redesigning the Clinical Learning Environment to Improve Interprofessional Care and Education: Multi-Method Program Evaluation of the iPACE Pilot Unit

BACKGROUND

In 2016, Maine Medical Center received an Accreditation Council for Graduate Medical Education Pursuing Excellence in Innovation grant to redesign the clinical learning environment to promote interprofessional care and education. The Interprofessional Partnership to Advance Care and Education (iPACE) model was developed and piloted on an adult inpatient medicine unit as an attempt achieve these aims.

OBJECTIVE

We describe the iPACE model and associated outcomes.

METHODS

Surveys and focus groups were employed as part of a multimethod pragmatic observational strategy. Team surveys included relational coordination (RC): a validated proprietary measure of interpersonal communication and relationships within teams. Pre-iPACE respondents were a representative historical sample from comparable inpatient medical units surveyed from March to April 2017. iPACE respondents were model participants surveyed March to August 2018 to allow for adequate sample size.

RESULTS

Surveys were administered to pre-iPACE (N = 113, response rate 74%) and iPACE (N = 32, 54%) teams. Summary RC scores were significantly higher for iPACE respondents (iPACE 4.26 [SD 0.37] vs 3.72 [SD 0.44], P < .0001), and these respondents were also more likely to report a professionally rewarding experience (iPACE 4.4 [SD 0.6] vs 3.5 [SD 1.0], P < .0001). Learners felt the model was successful in teaching interprofessional best practices but were concerned it may hinder physician role development. Patient experience was positive.

CONCLUSIONS

This pilot may have a positive effect on team functioning and team member professional experience and patient experience. Learner acceptance may be improved by increasing autonomy and preserving traditional learning venues.

Whose Patient Is This? A Scoping Review of Patient Ownership

PURPOSE

The scope of physicians' responsibility toward patients is becoming increasingly complicated to delimit as interdisciplinary care delivery and degrees of subspecialization increase. Patients can easily be lost across multiple transitions involved in care. Preparing learners to engage in safe and responsible patient care requires that we be clear about parameters of patient ownership. This scoping review (1) explores and synthesizes definitions of patient ownership and (2) describes the factors that influence patient ownership.

METHOD

Searching PubMed, Embase, and PsycINFO, the authors sought out publications of any format (i.e., original research papers, review articles, commentaries, editorials, and author discussions) that (1) addressed patient ownership directly or a closely related concept that explicitly affected patient ownership, (2) included medical care providers (attending/faculty physicians, medical residents, and/or medical students), and (3) were published in English. The authors analyzed findings to construct common themes and categorize findings.

RESULTS

Of 411 papers screened, 82 met our inclusion criteria. Twenty-three papers defined patient ownership in highly variable ways. Common themes across definitions included responsibility for patient care, personally carrying out patient care tasks, knowledge of patients' medical information, independent decision making, and putting patients' needs above one's own. Factors influencing patient ownership were (1) logistical concerns, (2) personal attributes, and (3) socially or organizationally constructed expectations.

CONCLUSIONS

A new definition of patient ownership is proposed encompassing findings from the review, while also respecting the shift from individual to a team-based patient care, and without removing the centrality of an individual provider's commitment to patients.

Implementation of Case Conferences to Improve Interprofessional Collaboration in Resident Continuity Clinic

OBJECTIVES

Residents must be trained in skills for interprofessional collaboration and team-based care in the outpatient setting, and successful models are needed to achieve this aim. A longitudinal curriculum was developed to enhance residents' knowledge of interprofessional team members' roles, residents' attitudes toward team-based care, and patient referrals to team members.

METHODS

Postgraduate year 1 through postgraduate year 3 internal medicine residents with continuity clinic at a large hospital-based practice received the curriculum. Residents with continuity clinic at another site did not receive the curriculum and served as controls. Intervention residents attended five small-group conferences during the course of 1 year, each dedicated to a specific interprofessional discipline: pharmacy, psychology, diabetes/nurse education, social work, and case management. Conferences involved interactive, case-based discussions of patients who benefit from an interprofessional approach. Control and intervention residents were surveyed with pre- and posttests. The rates of patient referrals to interprofessional team members were assessed.

RESULTS

Seventy-one residents received the curriculum. Intervention residents' knowledge of team members' names and roles, indications for patient referral, and communication methods improved after curriculum implementation. Attitudes toward team-based care did not change but were positive at baseline. Following curriculum implementation, new patient referrals increased for the pharmacist (0.1-1/100 patient visits, P = 0.015) and psychologist (1.1-2.2/100 patient visits, P = 0.032).

CONCLUSIONS

Case-based interprofessional conferences improved residents' knowledge regarding interprofessional care and increased referrals to team members. This curriculum addresses barriers to team-based care experienced by residents in continuity clinic and is adaptable to other clinic settings.

Perceptions of Iranian emergency department directors of interprofessional leadership: an interview study

The aim of this study was to explore the viewpoints of Iranian health-care team directors regarding factors that are influential in leading an interprofessional team in the emergency department. The study was conducted using in-depth individual interviews and inductive content analysis. The study took place in the emergency departments of three teaching hospitals in Tehran. We used purposeful criterion sampling and interviewed 15 health-care team directors including 12 emergency medicine specialists and 3 nursing directors. Each interview lasted 60 to 90 minutes. All interviews were recorded and transcribed verbatim. Participants' statements were used to freely generate the initial data codes (open coding). Then, the initial codes were arranged into subcategories, which were later grouped together into categories. Finally, by comparing and contrasting categories, three main categories were identified: (a) effectiveness of the team-based leadership, (b) strategies of advancing interprofessional collaboration, and (c) weakness in overcoming team challenges. In the present study, the main factors that affected developing interprofessional collaboration in the Iranian emergency department were the development and support of leadership at the team and organizational levels, and implementation of staff development strategies at the individual and team levels.

Factors influencing the acceptance of referrals for clinical pharmacist managed disease states in primary care

OBJECTIVE

Clinical pharmacists use population health methods to generate chronic disease management referrals for patients with uncontrolled chronic conditions. The purpose of this study was to compare primary care providers' (PCPs) referral responses for 4 pharmacist-managed indications and to identify provider and patient characteristics that are predictive of PCP response.

DESIGN

Retrospective cohort study.

SETTING

This study occurred in an academic internal medicine clinic.

PARTICIPANTS

Clinical pharmacy referrals generated through a population health approach between 2012 and 2016 for hypertension, chronic pain, depression, and benzodiazepine management were included.

MAIN OUTCOME MEASURES

Proportion of referrals accepted, left pending, or rejected and influencing provider and patient characteristics.

RESULTS

Of 1769 referrals generated, PCPs accepted 869 (49%), left pending 300 (17%), and rejected 600 (34%). Compared with referrals for hypertension, benzodiazepine management, and depression, chronic pain referrals had the lowest likelihood of rejection (odds ratio [OR] 0.31; 95% CI 0.19-0.49). Depression referrals had an equal likelihood of being accepted or rejected (OR 1.04; 95% CI 0.66-1.64). Provider characteristics were not significantly associated with referral response, but residents were more likely to accept referrals. Patient characteristics associated with lower referral rejection included black race (OR 0.39; 95% CI 0.18-0.87), higher systolic blood pressure (OR 0.98; 95% CI 0.97-0.99), and missed visits (OR 0.24; 95% CI 0.07-0.81).

CONCLUSION

The majority of referrals for clinical pharmacists in primary care settings were responded to, varying mostly between acceptance and rejection. There was variability in referral acceptance across indications, and some patient characteristics were associated with increased referral acceptance.

An Interprofessional Residency Clinic Curriculum for Geriatrics and Palliative Care

BACKGROUND AND OBJECTIVES

Caring for geriatrics and palliative care patients requires integrated interprofessional care. Studies regarding interprofessional education in family medicine reveal concerns by residents regarding applicability in future practice. Our study objective was to determine the effectiveness of teaching multispecialty geriatric and palliative care skills to family medicine residents using an interprofessional clinic curriculum.

METHODS

We evaluated an interprofessional geriatric and palliative care outpatient curriculum from March 2014 to June 2015. The interprofessional team included pharmacists, psychologists, family medicine geriatricians, and palliative care providers. Family medicine residents in a 3-year residency program completed pre- and postassessments evaluating their confidence and knowledge in specific areas of geriatric and palliative care. These assessments covered their abilities in starting advance care planning and setting goals in care discussions, as well as fall and depression assessment and elderly medication review. The subsequent resident perception of teaching effectiveness was also assessed. Qualitative comments were evaluated for themes. Patient perceptions were also surveyed.

RESULTS

Family medicine residents completed 52 surveys (51%). Improvements in all areas were significant (P<0.05). Postevaluation mean scores by year and by session demonstrated significant improvements in palliative care tools and teaching effectiveness. Qualitative comments revealed three themes: overall positive or negative educational value and understanding of assessments, reflection on interprofessional collaboration and team experience value, and improvements in logistics and collaboration. Patient satisfaction surveys reported improved satisfaction with their PCMH.

CONCLUSIONS

The use of an interprofessional and multispecialty clinic curriculum to teach geriatric and palliative care improved resident self-assessed knowledge and confidence as well as teaching effectiveness. Further studies evaluating resident exposure to such visits could substantiate the long-term influence of this educational endeavor.

Are role perceptions of residents and nurses translated into action?

BACKGROUND

Effective interprofessional collaboration (IPC) has been shown to depend on clear role definitions, yet there are important gaps with regard to role clarity in the IPC literature. The goal of this study was to evaluate whether there was a relationship between internal medicine residents' and nurses' role perceptions and their actual actions in practice, and to identify areas that would benefit from more specific interprofessional education.

METHODS

Fourteen residents and 14 nurses working in internal medicine were interviewed about their role perceptions, and then randomly paired to manage two simulated clinical cases. The authors adopted a general inductive approach to analyze the interviews. They identified 13 different role components that were then compared to data from simulations. Descriptive and kappa statistics were used to assess whether there was a relationship between role components identified in interviews and those performed in simulations. Results from these analyses guided a further qualitative evaluation of the relationship between role perceptions and actions.

RESULTS

Across all 13 role components, there was an overall statistically significant, although modest, relationship between role perceptions and actions. In spite of this relationship, discrepancies were observed between role components mentioned in interviews and actions performed in simulations. Some were more frequently performed than mentioned (e.g. "Having common goals") while others were mentioned but performed only weakly (e.g. "Providing feedback").

CONCLUSIONS

Role components for which perceptions do not match actions point to role ambiguities that need to be addressed in interprofessional education. These results suggest that educators need to raise residents' and nurses' awareness of the flexibility required to work in the clinical setting with regard to role boundaries.

Charting a Key Competency Domain: Understanding Resident Physician Interprofessional Collaboration (IPC) Skills

BACKGROUND

Interprofessional collaboration (IPC) is essential for quality care. Understanding residents' level of competence is a critical first step to designing targeted curricula and workplace learning activities. In this needs assessment, we measured residents' IPC competence using specifically designed Objective Structured Clinical Exam (OSCE) cases and surveyed residents regarding training needs.

METHODS

We developed three cases to capture IPC competence in the context of physician-nurse collaboration. A trained actor played the role of the nurse (Standardized Nurse - SN). The Interprofessional Education Collaborative (IPEC) framework was used to create a ten-item behaviorally anchored IPC performance checklist (scored on a three-point scale: done, partially done, well done) measuring four generic domains: values/ethics; roles/responsibilities; interprofessional communication; and teamwork. Specific skills required for each scenario were also assessed, including teamwork communication (SBAR and CUS) and patient-care-focused tasks. In addition to evaluating IPC skills, the SN assessed communication, history-taking and physical exam skills. IPC scores were computed as percent of items rated well done in each domain (Cronbach's alpha > 0.77). Analyses include item frequencies, comparison of mean domain scores, correlation between IPC and other skills, and content analysis of SN comments and resident training needs.

RESULTS

One hundred and seventy-eight residents (of 199 total) completed an IPC case and results are reported for the 162 who participated in our medical education research registry. IPC domain scores were: Roles/responsibilities mean = 37 % well done (SD 37 %); Values/ethics mean = 49 % (SD 40 %); Interprofessional communication mean = 27 % (SD 36 %); Teamwork mean = 47 % (SD 29 %). IPC was not significantly correlated with other core clinical skills. SNs' comments focused on respect and IPC as a distinct skill set. Residents described needs for greater clarification of roles and more workplace-based opportunities structured to support interprofessional education/learning.

CONCLUSIONS

The IPC cases and competence checklist are a practical method for conducting needs assessments and evaluating IPC training/curriculum that provides rich and actionable data at both the individual and program levels.