1
|
Han HJ, Ouellette MC, Yeh JC, Dodge LE, Finlay E, Cullinan AM, Buss MK. Outpatient Training During Hospice and Palliative Medicine Fellowship: A National Survey. J Pain Symptom Manage 2024:S0885-3924(24)00841-8. [PMID: 38945458 DOI: 10.1016/j.jpainsymman.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 07/02/2024]
Abstract
CONTEXT Outpatient palliative care (PC) has strong evidence demonstrating impact across serious illnesses, resulting in growing demand for skilled outpatient PC clinicians. However, there is limited literature examining the existing state and quality of outpatient PC education during postgraduate training. OBJECTIVES Characterize the current state of outpatient training in United States (US) Hospice and Palliative Medicine (HPM) physician fellowships and elicit perceptions regarding quality of outpatient PC education. METHODS A cross-sectional survey of US adult HPM fellowship program directors (PDs) or their designee conducted between March and July, 2023. RESULTS Of 161 programs, 85 participated (53% response rate) with representation across all US regions. HPM fellows spend a median of 4.8 weeks in outpatient PC compared to 24 weeks inpatient PC and 10.5 weeks in hospice settings. Over half (51%) of fellows saw outpatients from primarily one disease type with limited exposure to patients with other serious illnesses. Across programs, fellows' clinic structure, interdisciplinary team composition, and didactic experiences varied. On a 5-point rating scale, PDs reported significantly lower quality outpatient versus inpatient training (mean rating: 3.58 vs. 4.62, P<0.001) and perceived fellows as less prepared for independent outpatient practice upon graduation (mean: 4.06 vs. 4.73, P<0.001). CONCLUSION Our survey of US HPM fellowships identified multiple gaps between outpatient and inpatient PC education and training during fellowship and raises concern about the adequacy of outpatient PC training. To prepare the HPM workforce to meet the diverse needs of seriously ill populations and ensure adequate access, outpatient PC training requires reform.
Collapse
Affiliation(s)
- Harry J Han
- Section of Palliative Care (H.J.H, M.C.O., J.C.Y.), Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Michelle C Ouellette
- Section of Palliative Care (H.J.H, M.C.O., J.C.Y.), Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan C Yeh
- Section of Palliative Care (H.J.H, M.C.O., J.C.Y.), Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura E Dodge
- Department of Obstetrics and Gynecology (L.E.D.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Department of Epidemiology (L.E.D.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Esme Finlay
- Division of Palliative Medicine (E.F.), Department of Medicine, University of New Mexico School of Medicine, and the Raymond G Murphy Veterans Affairs Medical Center, Albuquerque, New Mexico
| | - Amelia M Cullinan
- Section of Palliative Care (A.M.C.), Department of Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, New Hampshire, Lebanon
| | - Mary K Buss
- Division of Palliative Care (M.K.B.), Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
2
|
O'Rourke P, Tackett S, Chacko K, Knaus SJ, Shalaby M, Fluker SA, Ma M, Overland M, Wright S. Factors Influencing Primary Care Career Choice: A Multi-Institutional Cross-sectional Survey of Internal Medicine Primary Care Residency Graduates. J Gen Intern Med 2024:10.1007/s11606-024-08846-z. [PMID: 38900381 DOI: 10.1007/s11606-024-08846-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Although primary care is associated with population health benefits, the supply of primary care physicians continues to decline. Internal medicine (IM) primary care residency programs have produced graduates that pursue primary care; however, it is uncertain what characteristics and training factors most affect primary care career choice. OBJECTIVE To assess factors that influenced IM primary care residents to pursue a career in primary care versus a non-primary care career. DESIGN Multi-institutional cross-sectional study. PARTICIPANTS IM primary care residency graduates from seven residency programs from 2014 to 2019. MAIN MEASURES Descriptive analyses of respondent characteristics, residency training experiences, and graduate outcomes were performed. Bivariate logistic regression analyses were used to assess associations between primary care career choice with both graduate characteristics and training experiences. KEY RESULTS There were 256/314 (82%) residents completing the survey. Sixty-six percent of respondents (n = 169) practiced primary care or primary care with a specialized focus such as geriatrics, HIV primary care, or women's health. Respondents who pursued a primary care career were more likely to report the following as positive influences on their career choice: resident continuity clinic experience, nature of the PCP-patient relationship, ability to care for a broad spectrum of patient pathology, breadth of knowledge and skills, relationship with primary care mentors during residency training, relationship with fellow primary care residents during training, and lifestyle/work hours (all p < 0.05). Respondents who did not pursue a primary care career were more likely to agree that the following factors detracted them from a primary care career: excessive administrative burden, demanding clinical work, and concern about burnout in a primary care career (all p < 0.05). CONCLUSIONS Efforts to optimize the outpatient continuity clinic experience for residents, cultivate a supportive learning community of primary care mentors and residents, and decrease administrative burden in primary care may promote primary care career choice.
Collapse
Affiliation(s)
- Paul O'Rourke
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Sean Tackett
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Karen Chacko
- Department of Medicine, University of Colorado, Denver, CO, USA
| | | | - Marc Shalaby
- Department of Medicine, Pennsylvania Hospital, Philadelphia, PA, USA
| | | | - Mina Ma
- Department of Medicine, UCLA, Los Angeles, CA, USA
| | - Maryann Overland
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Scott Wright
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
3
|
Snellings JE. Family Medicine and Internal Medicine: Let Our Powers Combine! PRIMER (LEAWOOD, KAN.) 2024; 8:19. [PMID: 38681816 PMCID: PMC11051689 DOI: 10.22454/primer.2024.657509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Affiliation(s)
- John E Snellings
- Department of Family and Community Medicine, Eastern Virginia Medical School, Norfolk, VA
| |
Collapse
|
4
|
Jordan KA, Gable EK, Morgan AP, McNeal-Trice K, Byerley JS. A Longitudinal Pediatric Primary Care Residency Tailored to Meet Workforce Need: A 10-Year Evaluation. J Grad Med Educ 2024; 16:80-83. [PMID: 38304590 PMCID: PMC10829916 DOI: 10.4300/jgme-d-23-00453.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/05/2023] [Accepted: 12/04/2023] [Indexed: 02/03/2024] Open
Abstract
Background We started a primary care residency program intended to prepare graduates for primary care and increase entry into primary care, using time-limited funds from the Health Resources and Services Administration (HRSA). Objective To compare the graduates of the primary care residency program to their categorical peers, and whether they remained in the state, began primary care careers, and whether they identified as underrepresented in medicine. Methods This is a retrospective study of a cohort of 39 residents who graduated from the University of North Carolina primary care residency program from 2014-2023. In 2016, HRSA grant funding expired and the program continued with ongoing financial support from the 2 institutions. Graduate demographics and career choices were compared to categorical residents (159 total) for graduate years 2014 to 2023. Results The primary care pediatrics residency has graduated 39 residents to date. Job placement data was obtained for all 39 graduates. Graduates of the program have 5.5-fold greater odds (95% CI, 2.5-12.5) of working in primary care roles following graduation than peer categorical residents. Most graduates (33 of 39, 85%) have taken jobs in general pediatrics (including primary care, urgent care, adolescent medicine, or hospital medicine). The program has recruited a large proportion of its residents (12 of 39, 31%) from groups historically underrepresented in medicine. Conclusions We developed an innovative primary care pediatric residency in collaboration with a community partner, spurred by HRSA funds, that has trained a diverse group of new primary care pediatricians.
Collapse
Affiliation(s)
- Katherine A. Jordan
- Katherine A. Jordan, MD, is Assistant Professor and Associate Program Director, Pediatric Residency Program, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Elizabeth Kaye Gable
- Elizabeth Kaye Gable, MD, is Professor and Program Director, Pediatric Primary Care Residency, Pediatric Teaching Program, Cone Health, Greensboro, North Carolina, USA
| | - Andrew P. Morgan
- Andrew P. Morgan, MD, PhD, is Assistant Professor, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Kenya McNeal-Trice
- Kenya McNeal-Trice, MD, is Professor and Vice Chair of Education, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; and at the time of writing
| | - Julie S. Byerley
- Julie S. Byerley, MD, MPH, was Professor and Vice Dean for Academic Affairs and Chief Education Officer, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA, and is now Professor and President and Dean, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| |
Collapse
|
5
|
Nandiwada DR, Farkas AH, Nikiforova T, Leung PB, Donovan AK, Killian K, Thomas ML, Singh MK, Gallagher B, Callender DM. Exploring Models of Exposure to Primary Care Careers in Training: a Narrative Review. J Gen Intern Med 2024; 39:277-282. [PMID: 37989819 PMCID: PMC10853099 DOI: 10.1007/s11606-023-08532-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/08/2023] [Indexed: 11/23/2023]
Abstract
Multiple models of clinical exposure to primary care exist within undergraduate medical education (UME) and graduate medical education (GME). In this narrative review, we explore the evidence behind these different models of exposure, their alignment with positive promoters of primary care careers, and the pros and cons of each. Without positive exposure to primary care during training, sustaining the future primary care work force becomes increasingly challenging. Here, we explore multiple models of clinical exposure in UME, including longitudinal integrated clerkships, primary care tracks, and primary care clerkships. Within GME, we will review the impact of primary care tracks, Area Health Education Centers, block scheduling models, and continuity clinic scheduling models. The goal of this narrative review is to allow educators to think broadly and intentionally about the array of models to develop positive primary care experiences and perceptions in training, ultimately sustaining the primary care workforce.
Collapse
Affiliation(s)
- D Rani Nandiwada
- Perelman School of Medicine, University of Pennsylvania, 51 North 39Th Street, MAB 102, Philadelphia, PA, 19104, USA
| | - Amy H Farkas
- Milwaukee VA Medical Center, 5000 W National Ave, Milwaukee, WI, 53211, USA
| | - Tanya Nikiforova
- Division of General Internal Medicine, UPMC Montefiore Hospital, 9 West 921, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Peggy B Leung
- Weill Cornell Internal Medicine Associates, 505 East 70Th St, HT-4, New York, NY, 10021, USA
| | - Anna K Donovan
- Division of General Internal Medicine, UPMC Montefiore Hospital, 9 West 930, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Katherine Killian
- Weill Cornell Internal Medicine, 178 East 85Th Street, Floor 2, New York, NY, 10028, USA
| | - Mary L Thomas
- University of Tennessee, 920 Madison Ave, Suite 531, Memphis, TN, 38163, USA
| | - Mamta K Singh
- Case Western Reserve University, VA Northeast Ohio Healthcare System, 1620 Magnolia Drive, Administrative Building, RM 5M678, Cleveland, OH, 44106, USA
| | | | - David M Callender
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.
| |
Collapse
|
6
|
Tort-Nasarre G, Vidal-Alaball J, Pedrosa MJF, Abanades LV, Arcarons AF, Rosanas JD. Factors associated with the attraction and retention of family and community medicine and nursing residents in rural settings: a qualitative study. BMC MEDICAL EDUCATION 2023; 23:662. [PMID: 37705018 PMCID: PMC10500790 DOI: 10.1186/s12909-023-04650-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND The current shortage of primary care doctors and nurses is causing difficulties in replacement, and this shortage is expected to increase. This situation is more pronounced in rural environments than in urban ones. Family and community care specialty training is a key component of both the transition to clinical practice and the retention of new professionals. The aim of this study is to explore the attitudes and perceptions of internal medicine residents and internal nurse residents trained in a rural teaching unit on factors associated with recruitment and retention, including the role of the specialty training programme. METHODS A qualitative study was conducted. Purposive sampling was used, and thirteen residents from the central Catalonia teaching unit who were in their final year of training participated in semistructured interviews. The data were collected during 2022 and were subsequently analysed with thematic analysis. The study is reported using the COREQ checklist. RESULTS Six themes emerged from data related to perceptions and attitudes about the factors associated with recruitment and retention: training programme, characteristics of the family and community specialty, concept of rural life, family and relational factors, economic and resource factors, and recruitment and job opportunities. CONCLUSIONS Family and community medicine and nursing residents trained in rural settings expressed satisfaction with the specialty programme and most features of primary care, but they experienced a wide range of uncertainties in deciding on their professional future in terms of living in rural areas, family support, financial support and recruitment. This study identifies individual and structural factors that could be of great use to retain doctors and nurses in rural areas.
Collapse
Affiliation(s)
- G Tort-Nasarre
- Department of Nursing, Faculty of Nursing and Physiotherapy, University of Lleida, C/Montserrat Roig, Lleida, 25198, Spain
- SAP ANOIA. Gerencia Territorial Catalunya Central, Institut Català de La Salut, Igualada, 08700, Spain
| | - Josep Vidal-Alaball
- Unitat de Suport a la Recerca de la Catalunya Central, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Sant Fruitós del Bages, 08272, Spain.
- Health Promotion in Rural Areas Research Group, Gerencia Territorial de la Catalunya Central, Institut Català de la Salut, Sant Fruitós de Bages, 08272, Spain.
- University of Vic-Central University of Catalonia, Vic, 08500, Spain.
| | - M J Fígols Pedrosa
- Unitat Docent Multiprofessional d'AFiC Catalunya Central, Gerència Territorial de la Catalunya Central, Institut Català de la Salut, Sant Fruitós de Bages, 08272, Spain
| | - L Vazquez Abanades
- Unitat Docent Multiprofessional d'AFiC Catalunya Central, Gerència Territorial de la Catalunya Central, Institut Català de la Salut, Sant Fruitós de Bages, 08272, Spain
| | - A Forcada Arcarons
- Gerència Territorial de la Catalunya Central, Institut Català de la Salut, 13-15, Sant Fruitós de Bages, 08272, Spain
| | - J Deniel Rosanas
- Department of Nursing, Faculty of Nursing and Physiotherapy, University of Lleida, C/Montserrat Roig, Lleida, 25198, Spain
| |
Collapse
|
7
|
Chen KL, Yuan SE, Asfaw EK, Sim MS, Ntim GMJ, Ma MW, Pessegueiro AM. Near-Peer Supervision in Primary Care: Bringing Teaching Teams From the Wards to the Clinic. J Grad Med Educ 2023; 15:481-487. [PMID: 37637346 PMCID: PMC10449350 DOI: 10.4300/jgme-d-22-00830.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/14/2023] [Accepted: 05/30/2023] [Indexed: 08/29/2023] Open
Abstract
Background Teaching near-peers yields numerous benefits to residents. Opportunities for near-peer teaching are typically restricted to hospital settings. Little is known about the educational potential of outpatient near-peer teaching. Objective To describe Primary Care Teaching (PC Teach), a novel outpatient near-peer teaching experience for residents in a large, urban, internal medicine residency program; characterize its feasibility and acceptability; and evaluate changes in residents' self-reported confidence in outpatient teaching and attitudes toward teaching and primary care/outpatient medicine. Methods In 2020-2021, following a didactic workshop, 43 postgraduate year 3 (PGY-3) residents at continuity clinics assigned to PC Teach completed a series of half-day sessions acting as preceptor to interns under attending supervision. Worksheets facilitated post-session feedback for residents and interns. Eighteen PGY-3s at nonparticipating clinics, who also completed the workshop, served as controls. We assessed process measures for feasibility and acceptability and analyzed resident attitudes using pre-post surveys. Results Participating residents completed 2 to 8 sessions each. Post-intervention scores for confidence in outpatient teaching and attitudes toward teaching were greater, relative to pre-intervention group means, for intervention residents (median pre-post changes +0.60 [IQR 0.26, 1.26] and +0.46 [-0.04, 0.46], respectively) vs controls (-0.15 [-0.48, 0.85] and -0.36 [-0.86, 0.39]; between-group differences +0.75 [P=.03] and +0.82 [P=.02]). Changes in attitudes toward primary care/outpatient medicine did not differ significantly between intervention and control groups (+0.43 [-0.07, 0.68] and 0.04 [-0.58, 0.42]; between-group difference +0.39 [P=.12]). In multivariable analyses, odds of gains in confidence in outpatient teaching remained significantly larger for intervention residents vs controls. Conclusions Implementing PC Teach with existing resources was feasible and acceptable, with program flexibility highlighted as a strength. Resident participation was associated with greater confidence in outpatient teaching.
Collapse
Affiliation(s)
- Katherine L. Chen
- Katherine L. Chen, MD, PhD, is Clinical Instructor and Postdoctoral Fellow, Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine, University of California, Los Angeles (UCLA)
| | - Stanley E. Yuan
- Stanley E. Yuan, MD, is a Hospitalist, Division of General Internal Medicine, Cedars Sinai Medical Center
| | - Elizabeth K. Asfaw
- Elizabeth K. Asfaw, MD, is Clinical Instructor, Department of Medicine, David Geffen School of Medicine, UCLA
| | - Myung Shin Sim
- Myung Shin Sim, DrPH, MS, is Associate Professor, Department of Medicine, David Geffen School of Medicine, UCLA
| | - Gifty-Maria J. Ntim
- Gifty-Maria J. Ntim, MD, MPH, is Assistant Clinical Professor, Department of Medicine, David Geffen School of Medicine, UCLA
| | - Mina W. Ma
- Mina W. Ma, MD, is Clinical Professor, Department of Medicine, David Geffen School of Medicine, UCLA; and
| | - Antonio M. Pessegueiro
- Antonio M. Pessegueiro, MD, is Associate Clinical Professor, Department of Medicine, David Geffen School of Medicine, UCLA
| |
Collapse
|
8
|
Moldestad M, Sayre G, Rinne S, Kaboli PJ, Reddy A, Sanders KM, Mao J, Henrikson NB, Sterling R, Nelson KM, Wong ES. Perspectives on Training and Working in the VHA: Implications for Primary Care Physician Recruitment and Retention. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1175-1183. [PMID: 35139527 DOI: 10.1097/acm.0000000000004619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE The primary care physician shortage in the United States presents significant challenges for health systems seeking to maintain a sufficient primary care workforce. Perspectives on training or working in primary care in the Veterans Health Administration (VHA) may yield insights into strategic recruitment to make the VHA and other health systems more attractive to primary care physicians. The authors sought to understand the experiences of resident and staff physicians with limited tenure within VHA primary care to identify factors to guide health systems in improving recruitment and retention. METHOD This qualitative exploratory study was conducted from June 2018 to October 2019 with 24 internal medicine residents and 30 staff physicians in VHA primary care. Heterogeneity was ensured by sampling for geographical region, rurality, and gender within each cohort. The authors conducted semistructured interviews to ascertain perspectives on training and employment preferences at VHA and non-VHA sites. Combined content analysis was used to generate findings. RESULTS The authors identified 4 key themes, centered around shared values and the VHA's mission-driven culture: the VHA "community" was perceived as unique and a major contributor to job satisfaction; facility-level leadership support was important to perceptions of workplace culture around harassment; the VHA primary care delivery model allowed residents and staff physicians to get patients needed care but did not always live up to its potential; and VHA employment was better than expected, but the process of getting hired was a challenge. CONCLUSIONS Mission and workplace culture may serve important roles in the desirability of health systems for prospective physicians and the job satisfaction of physicians who work in these systems. Physician recruitment efforts based on these attributes may yield the most success in maintaining a sufficient physician workforce.
Collapse
Affiliation(s)
- Megan Moldestad
- M. Moldestad is a qualitative analyst, Seattle-Denver Center of Innovation, Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, and a doctoral student, Department of Human Centered Design and Engineering, University of Washington, Seattle, Washington; ORCID: https://orcid.org/0000-0002-0239-6120
| | - George Sayre
- G. Sayre is a qualitative methodologist and director, Qualitative Research Core, Seattle-Denver Center of Innovation, Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, and clinical assistant professor, Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington
| | - Seppo Rinne
- S. Rinne is a clinician-investigator, Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts, and assistant professor, Pulmonary Center, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Peter J Kaboli
- P.J. Kaboli is an investigator and professor of medicine, Iowa City Veterans Affairs Healthcare System and University of Iowa Carver College of Medicine, Iowa City, Iowa; ORCID: https://orcid.org/0000-0003-0993-0952
| | - Ashok Reddy
- A. Reddy is a clinician-investigator, Seattle-Denver Center of Innovation, Department of Health Services Research and Development, and General Medicine Service, Veterans Affairs Puget Sound Health Care System, and associate professor, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
| | - Karen M Sanders
- K.M. Sanders is deputy chief, Office of Academic Affiliations, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC
| | - Johnny Mao
- J. Mao is a project coordinator and research health science specialist, Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Nora B Henrikson
- N.B. Henrikson is assistant investigator, Kaiser Permanente Washington Health Research Institute, and holds affiliate faculty appointments, Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington, and Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Ryan Sterling
- R. Sterling is a research scientist, Seattle-Denver Center of Innovation, Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; ORCID: https://orcid.org/0000-0003-1217-5409
| | - Karin M Nelson
- K.M. Nelson is a clinician-investigator, Seattle-Denver Center of Innovation, Department of Health Services Research and Development, and General Medicine Service, Veterans Affairs Puget Sound Health Care System, and professor, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
| | - Edwin S Wong
- E.S. Wong is a core investigator, Seattle-Denver Center of Innovation, Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, and research associate professor, Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington
| |
Collapse
|
9
|
Graham KL, Glassman AR, Davis RB, Ayub M, Libman H, Reynolds E. Effect of an Immersive Primary Care Training Program on Educational and Clinical Outcomes in an Internal Medicine Residency Training Program: Meeting the Training Needs of a Modern-Day Physician Workforce. J Gen Intern Med 2022; 37:2634-2641. [PMID: 34625856 PMCID: PMC9411496 DOI: 10.1007/s11606-021-07101-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Residents planning careers in primary care have unique training needs that are not addressed in traditional internal medicine training programs, where there is a focus on inpatient training. There are no evidence-based approaches for primary care training. OBJECTIVES Design and test the effect of a novel immersive primary care training program on educational and clinical outcomes. DESIGN Nested intervention study. SETTING, PARTICIPANTS Twelve primary care residents, 86 of their categorical peers, and an 11-year historical cohort of 69 primary care trainees in a large urban internal medicine residency training program. INTERVENTIONS Two 6-month blocks of primary care immersion alternating with two 6-month blocks of standard residency training during the second and third post-graduate years. MAIN MEASURES Total amount of ambulatory and inpatient training time, subjective and objective educational outcomes, clinical performance on cancer screening, and chronic disease management outcomes. KEY RESULTS Participants in the intervention increased ambulatory training in both general medicine and specialty medicine and still met all ACGME training requirements. Residents reported improved subjective educational outcomes on a variety of chronic disease management topics and ambulatory care skills. They reported higher satisfaction with the amount of ambulatory training (4.3/5 vs. 3.6/5, p=0.008), attended more ambulatory clinics (242 vs. 154, p<0.001), and carried larger, more complicated panels (173 vs. 90 patients, p<0.001). They also performed better on diabetes management (86% vs. 76% control, p<0.001). Alumni who completed the intervention reported higher primary care career preparation (79% response rate) than those who did not (85% response rate) among an 11-year cohort of primary care alumni (4/5 vs. 3/5, p<0.001). CONCLUSIONS A primary care training program that provides clinical immersion in the ambulatory setting improved educational outcomes for trainees and clinical outcomes for their patients. Providing more training in the ambulatory environment should be a priority in graduate medical education.
Collapse
Affiliation(s)
- Kelly L Graham
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | | | - Roger B Davis
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Mariam Ayub
- Division of General Internal Medicine, Medstar Georgetown University Medical Center, Washington, DC, USA
| | - Howard Libman
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Eileen Reynolds
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| |
Collapse
|
10
|
Wild D, Linden K, Welchowski T, Dehnen D, Weltermann B. Attitudes of German GP trainees regarding add-on training programs differ if in office or hospital training phase. BMC MEDICAL EDUCATION 2022; 22:205. [PMID: 35346168 PMCID: PMC8959794 DOI: 10.1186/s12909-022-03273-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 03/15/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Many residents are exposed to negative attitudes towards primary care during hospital training. Attractive add-on training programs exist, but it is unclear whether these need to be tailored to the location of training (hospital vs. office). We report differences in learner attitudes from a large German add-on training program. METHODS Between 2017 and 2020, a regional network offered 31 quarterly seminars to primary care residents. The seminars addressed medical content, practice management and mentoring. We elicited participants' satisfaction, perceived topic relevance, preferences for future seminars, work situation and employer support for participation. A proportionate odds model was used to assess predictors of ratings; results were stratified by training location (hospital vs. office). RESULTS Most respondents were female (380/575 = 70.0%), aged between 26 and 40 (80.8%), and had on average 3.54 ± 1.64 years of residency training. The majority (83.8%) was working in an office and full-time (63.0%). Overall evaluations were positive (very satisfactory 72.1%). Comparing residents in the hospital phase vs. the office phase, overall seminar ratings of the perceived impact on the motivation for primary care did not differ (p = 0.73 vs. 0.18, respectively). Hospital-based residents were less likely to rate the topics as relevant (39.4% vs. 55.7%, p = 0.02) and had different preferences for future seminar topics (top 3: palliative care, emergencies and chronic care vs. billing, disease management and practice finances for hospital and office phase, respectively). CONCLUSIONS Keeping primary care residents motivated may require education tailored to training location. Our findings may be of interest to teachers, administrators and policymakers.
Collapse
Affiliation(s)
- Dmg Wild
- Institute of Family Medicine and General Practice, University Hospital Bonn, University of Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany.
| | - K Linden
- Institute of Family Medicine and General Practice, University Hospital Bonn, University of Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany
| | - T Welchowski
- Institute of Family Medicine and General Practice, University Hospital Bonn, University of Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany
- Institute of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - D Dehnen
- Institute of Family Practice, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - B Weltermann
- Institute of Family Medicine and General Practice, University Hospital Bonn, University of Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany
| |
Collapse
|
11
|
Fraze TK, Beidler LB, Gottlieb LM. A Missed Opportunity? How Health Care Organizations Engage Primary Care Clinicians in Formal Social Care Efforts. Popul Health Manag 2022; 25:509-516. [PMID: 35196116 PMCID: PMC9419929 DOI: 10.1089/pop.2021.0306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Health care organizations increasingly recognize the impact of social needs on health outcomes. As organizations develop and scale efforts to address social needs, little is known about the optimal role for clinicians in providing social care. In this study, the authors aimed to understand how health care organizations involve clinicians in formal social care efforts. In 2019, the authors conducted 33 semi-structured interviews with administrators at 29 health care organizations. Interviews focused on the development and implementation of formal social care programs within the health care organization and the role of clinicians within those programs. A few administrators described formal roles for primary care clinicians in organizational efforts to deliver social care. Administrators frequently described programs that were deliberately structured to shield clinicians (eg, clinicians were not expected to review social risk screening results or be involved in addressing social needs). The authors identified 4 ways that administrators felt clinicians could meaningfully engage in social care programs: (1) discuss social risks to strengthen relationships with patients; (2) adjust clinical care follow-up plans based on social risks; (3) modify prescriptions based on social risks; and (4) refer patients to other care team members who can directly assist with social risks. Administrators were hesitant to increase primary care clinicians' responsibilities by tasking them with social care activities. Defining appropriate and scalable roles for clinicians along with adequate support from other care team members may increase the effectiveness of social care programs.
Collapse
Affiliation(s)
- Taressa K Fraze
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California, USA.,Healthforce Center, University of California San Francisco, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Laura B Beidler
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Laura M Gottlieb
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
12
|
Strasser JH, Jewers MM, Kepley H, Chen C, Erikson C, Regenstein M. A Mixed-Methods Study of Teaching Health Center Residents' Experiences of Mentorship, Career Planning, and Postresidency Practice Environments. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:129-135. [PMID: 34554952 DOI: 10.1097/acm.0000000000004419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE The Teaching Health Center (THC) Graduate Medical Education program enables primary care physicians to train in community-based, underserved settings by shifting the payment structure and training environment for graduate medical education. To understand how THCs have successfully trained primary care physicians who practice in community-based settings, the authors conducted a mixed-methods exploratory study to examine THC residency graduates' experiences of mentorship and career planning during their residencies, perceptions of preparation for postresidency practice, and how these experiences were related to postresidency practice environments. METHOD Surveys were conducted for all 804 graduating THC residents nationally, 2014-2017 (533 respondents, 66% response rate). Three quantitative outcomes were measured: graduates' perceptions of preparation for practice after residency (Likert scale), satisfaction with mentorship and career planning (Likert scale), and characteristics of postresidency practice environment (open-ended). A qualitative analysis of open-text survey answers, using thematic content analysis, was also conducted. RESULTS Most THC graduates (68%) were satisfied with their mentorship and career planning experience and generally felt prepared for postresidency practice in multiple settings (78%-93%). Of the 533 THC graduates who provided information about their practice environment, 445 (84%) were practicing in primary care; nationally, 64% of physicians who completed primary care residencies practiced in primary care. Of the 445 THC graduates practicing in primary care, 12% practiced in rural areas, compared with 7% of all physicians. Just over half of THC graduates (51%) practiced in medically underserved areas, compared with 39% of all physicians. CONCLUSIONS This study offers early evidence that the THC model produces and retains primary care physicians who are well prepared to practice in underserved areas. Given these promising findings, there appears to be a substantial benefit to growing the THC program. However, the program continues to face uncertainty around ongoing, stable funding.
Collapse
Affiliation(s)
- Julia H Strasser
- J.H. Strasser is senior research scientist, Fitzhugh Mullan Institute for Health Workforce Equity, Department of Health Policy and Management, George Washington University Milken Institute School of Public Health, Washington, DC
| | - Mariellen M Jewers
- M.M. Jewers is cofounder and vice president, Open Avenues Foundation, and chief operating officer, Project Alianza, Boston, Massachusetts
| | - Hayden Kepley
- H. Kepley is deputy director, National Center for Health Workforce Analysis, Bureau of Health Workforce, Health Resources and Services Administration, Rockville, Maryland
| | - Candice Chen
- C. Chen is associate professor of health policy and management, Fitzhugh Mullan Institute for Health Workforce Equity, Department of Health Policy and Management, George Washington University Milken Institute School of Public Health, Washington, DC
| | - Clese Erikson
- C. Erikson is deputy director, Health Workforce Research Center on Health Professions Education and Training, Fitzhugh Mullan Institute for Health Workforce Equity, Department of Health Policy and Management, George Washington University Milken Institute School of Public Health, Washington, DC
| | - Marsha Regenstein
- M. Regenstein is professor, Department of Health Policy and Management, George Washington University Milken Institute School of Public Health, Washington, DC
| |
Collapse
|
13
|
Factors Associated with a Career in Primary Care Medicine: Continuity Clinic Experience Matters. J Gen Intern Med 2021; 36:3383-3387. [PMID: 33620629 PMCID: PMC8606375 DOI: 10.1007/s11606-021-06625-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Due to concerns of inadequate primary care access, national agencies like the Health Resources and Services Administration (HRSA) support primary care (PC) residencies. Recent research demonstrates that up to 35% of PC alumni lost interest in PC during residency. These alumni who lost interest noted that their continuity clinic experience influenced their career choice. The purpose of this study was to identify the specific aspects of PC residency experience that influenced career choice. METHODS We conducted a cross-sectional electronic survey of a PC internal medicine alumni cohort (2000-2015) from a large, academic residency. Our primary predictor was PC career and our primary outcome was influential factors on career choice. We performed chi-squared or Fisher's exact tests for categorical variables and t tests for continuous variables. RESULTS Of the 317 PC alumni in the last 15 years, 305 were contacted. One hundred seventy-two (56%) responded with 94 (55%) reporting current careers in PC and 78 (45%) in non-PC fields. Ninety-four percent of respondents expressed interest prior to residency, while only 68% remained interested at the conclusion of residency. Sixty-one percent of PC alumni rated the overall clinic experience as the most influential factor towards their ultimate career choice. The patient-physician relationship was the most frequently endorsed positively influential factor in career choice in both groups (95% of PC alumni, 76% non-PC). There was no difference among all alumni in common frustrations of clinic including clerical duties, encounter documentation, or visit length. Similarly, resident debt did not differ between groups. CONCLUSIONS Strong interpersonal relationships with patients and clinic mentors were associated with a PC career. These factors may compensate for the reported frustrations of clinic. Enhancing patient and mentor relationships may increase the retention of PC residents in ambulatory careers and may help address the current and projected shortage of primary care physicians.
Collapse
|
14
|
Abrahams S, Kim EJ, Marrast L, Uwemedimo O, Conigliaro J, Martinez J. Examination of resident characteristics associated with interest in primary care and identification of barriers to cross-cultural care. BMC MEDICAL EDUCATION 2021; 21:218. [PMID: 33874946 PMCID: PMC8056670 DOI: 10.1186/s12909-021-02669-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/05/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND There is an increasing shortage of primary care physicians in the U.S. The difficult task of addressing patients' sociocultural needs is one reason residents do not pursue primary care. However, associations between residents' perceived barriers to cross-cultural care provision and career interest in primary care have not been investigated. OBJECTIVE We examined residents' career interest in primary care and associations with resident characteristics and their perceived barriers in providing cross-cultural care. METHODS We conducted a cross-sectional analysis of a resident survey from the 2018-2019 academic year. We first described residents' sociodemographic characteristics based on their career interest in primary care (Chi-square test). Our primary outcome was high career interest in primary care. We further examined associations between residents' characteristics and perceived barriers to cross-cultural care. RESULTS The study included 155 family medicine, pediatrics, and internal medicine residents (response rate 68.2%), with 17 expressing high career interest in primary care. There were significant differences in high career interest by race/ethnicity, as Non-White race was associated with high career interest in primary care (p < 0.01). Resident characteristics associated with identifying multiple barriers to cross-cultural care included disadvantaged background, multilingualism, and foreign-born parents (all p-values< 0.05). There were no significant associations between high career interest in primary care and barriers to cross-cultural care. CONCLUSION Residents from diverse racial/ethnic and socioeconomic backgrounds demonstrated higher career interest in primary care and perceived more barriers to cross-cultural care, underscoring the importance of increasing physician workforce diversity to address the primary care shortage and to improve cross-cultural care.
Collapse
Affiliation(s)
- Sara Abrahams
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, NY, 11549, USA.
| | - Eun Ji Kim
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| | - Lyndonna Marrast
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| | - Omolara Uwemedimo
- Occupational Medicine, Epidemiology, and Prevention at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
| | - Joseph Conigliaro
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| | - Johanna Martinez
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| |
Collapse
|
15
|
Holt SR, Tobin DG, Whitman L, Ellman M, Moriarty JP, Doolittle B. Creating a Satisfying Continuity Clinic Experience for Primary Care Trainees. Am J Med 2021; 134:547-553. [PMID: 33385340 DOI: 10.1016/j.amjmed.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/17/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen R Holt
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn.
| | - Daniel G Tobin
- St. Raphael's Adult Primary Care Center of Yale-New Haven Hospital, Conn
| | - Laura Whitman
- York Street Campus Primary Care Center of Yale-New Haven Hospital, Conn
| | - Matthew Ellman
- Yale Internal Medicine Associates, Yale School of Medicine, New Haven, Conn
| | - John P Moriarty
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn
| | - Benjamin Doolittle
- Yale Internal Medicine-Pediatrics Residency Program, Yale School of Medicine, New Haven, Conn
| |
Collapse
|
16
|
Raj M, Platt JE, Anthony DL, Fitzgerald JT, Lee SYD. Exploring How Personal, Social, and Institutional Characteristics Contribute to Geriatric Medicine Subspecialty Decisions: A Qualitative Study of Trainees' Perceptions. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:425-432. [PMID: 33031118 DOI: 10.1097/acm.0000000000003784] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE To explore internal medicine residents' and geriatrics fellows' perceptions of how personal, social, and institutional characteristics contribute to their professional identity and subspecialty decisions related to geriatric medicine. METHOD The authors conducted 23 in-depth, semistructured interviews with internal medicine residents, with and without an interest in geriatrics, and geriatrics fellows across 3 academic medical centers in the United States from October 2018 through June 2019. They then used a qualitative narrative approach to analyze the interview data. RESULTS Trainees related personal experiences, such as exposure to physicians and experiences with grandparents, to their interest in medicine. Trainees with an interest in geriatrics at 2 institutions did not feel supported, or understood, by peers and mentors in their respective institutions but maintained their interest in the field. The following variations between institutions that are supportive and those that are not were noted: the number of geriatricians, the proximity of the institution to geriatrics clinics, and the ways in which institutional leaders portrayed the prestige of geriatric medicine. Institutional characteristics influenced trainees' understanding of what it meant to be a doctor, what meaning they garnered from work as a physician, and their comfort with different types of complexity, such as those presented when providing care to older adults. CONCLUSIONS Institutional characteristics may be particularly important in shaping trainee interest in geriatric medicine. Institutions should encourage leadership training and opportunities for geriatricians so they can serve as role models and as hands-on mentors for trainees beginning in medical school. Increasing the number of geriatricians requires institutions to increase the value they place on geriatrics to generate a positive interest in this field among trainees. Institutions facilitating formation of professional identity and sense of purpose in work may consider engaging geriatricians in leadership and mentoring roles as well as curriculum development.
Collapse
Affiliation(s)
- Minakshi Raj
- M. Raj is assistant professor, Department of Kinesiology and Community Health, University of Illinois at Urbana Champaign, Champaign, Illinois; ORCID: http://orcid.org/0000-0002-1457-7850
| | - Jodyn E Platt
- J.E. Platt is assistant professor, Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Denise L Anthony
- D.L. Anthony is professor, Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - James T Fitzgerald
- J.T. Fitzgerald is professor, Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Shoou-Yih Daniel Lee
- S.-Y.D. Lee is professor, Department of Health Administration, Virginia Commonwealth University, Richmond, Virginia
| |
Collapse
|
17
|
O’Sullivan B, McGrail M, Gurney T, Martin P. A Realist Evaluation of Theory about Triggers for Doctors Choosing a Generalist or Specialist Medical Career. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228566. [PMID: 33218189 PMCID: PMC7699208 DOI: 10.3390/ijerph17228566] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/09/2020] [Accepted: 11/17/2020] [Indexed: 01/29/2023]
Abstract
There is a lack of theory about what drives choice to be a generalist or specialist doctor, an important issue in many countries for increasing primary/preventative care. We did a realist evaluation to develop a theory to inform what works for whom, when and in what contexts, to yield doctors’ choice to be a generalist or specialist. We interviewed 32 Australian doctors (graduates of a large university medical school) who had decided on a generalist (GP/public health) or specialist (all other specialties) career. They reflected on their personal responses to experiences at different times to stimulate their choice. Theory was refined and confirmed by testing it with 17 additional doctors of various specialties/career stages and by referring to wider literature. Our final theory showed the decision involved multi-level contextual factors intersecting with eight triggers to produce either a specialist or generalist choice. Both clinical and place-based exposures, as well as attributes, skills, norms and status of different fields affected choice. This occurred relative to the interests and expectations of different doctors, including their values for professional, socio-economic and lifestyle rewards, often intersecting with issues like gender and life stage. Applying this theory, it is possible to tailor selection and ongoing exposures to yield more generalists.
Collapse
Affiliation(s)
- Belinda O’Sullivan
- Faculty of Medicine, The University of Queensland, Rural Clinical School, Locked Bag 9009, Toowoomba 4350, DC Queensland, Australia; (T.G.); (P.M.)
- Correspondence: ; Tel.: +61-4-2740-5030
| | - Matthew McGrail
- Faculty of Medicine, The University of Queensland Rural Clinical School, 78 on Canning St, Rockhampton 4700, Queensland, Australia;
| | - Tiana Gurney
- Faculty of Medicine, The University of Queensland, Rural Clinical School, Locked Bag 9009, Toowoomba 4350, DC Queensland, Australia; (T.G.); (P.M.)
| | - Priya Martin
- Faculty of Medicine, The University of Queensland, Rural Clinical School, Locked Bag 9009, Toowoomba 4350, DC Queensland, Australia; (T.G.); (P.M.)
| |
Collapse
|
18
|
Trends and factors affecting the US adult hematology workforce: a mixed methods study. Blood Adv 2020; 3:3550-3561. [PMID: 31738829 DOI: 10.1182/bloodadvances.2019000307] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/02/2019] [Indexed: 11/20/2022] Open
Abstract
The current demand for adult hematologists in the United States is projected to exceed the existing supply. However, no national study has systematically evaluated factors affecting the adult hematology workforce. In collaboration with the American Society of Hematology (ASH), we performed a mixed methods study consisting of surveys from the annual ASH In-Service Exam for adult hematology/oncology fellows from 2010 to 2016 (8789 participants); interviews with graduating or recently graduated adult hematology/oncology fellows in a single training program (8 participants); and 3 separate focus groups for hematology/oncology fellowship program directors (12 participants), fellows (12 participants), and clinicians (10 participants) at the 2016 ASH annual meeting. In surveys, the majority of fellows favored careers combining hematology and oncology, with more fellows identifying oncology, rather than hematology, as their primary focus. In interviews with advanced-year fellows, mentorship emerged as the single most important career determinant, with mentorship opportunities arising serendipitously, and oncology faculty perceived as having greater availability for mentorship than hematology faculty. In focus group discussions, hematology, particularly benign hematology, was viewed as having poorer income potential, research funding, job availability, and job security than oncology. Focus group participants invariably agreed that the demand for clinical care in hematology, particularly benign hematology, exceeded the current workforce supply. Single-subspecialty fellowship training in hematology and the creation of new clinical care models were offered as potential solutions to these workforce problems. As a next step, ASH is conducting a national, longitudinal study of the adult hematology workforce to improve recruitment and retention in the field.
Collapse
|
19
|
Deeds SA. Expanding Primary Care Experiences With Novel Rotations for Residents at a VA Medical Center. J Grad Med Educ 2019; 11:691-697. [PMID: 31871571 PMCID: PMC6919180 DOI: 10.4300/jgme-d-19-00147.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 08/01/2019] [Accepted: 09/30/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The number of graduating primary care physicians will not meet the demands of the growing and aging US population. In 2011, the Veterans Affairs (VA) Office of Academic Affiliations established 5 Centers of Excellence in Primary Care Education (CoEPCE) to transform primary care training. OBJECTIVE We created an innovative training model with immersive primary care experiences to foster careers in primary care for residents. METHODS As a CoEPCE, the Seattle VA partnered with the University of Washington internal medicine residency program to form a Center of Excellence (CoE) pathway with increased outpatient training time. The CoEPCE created a longitudinal curriculum of continuity clinic immersion and new thematically based rotations (eg, Homeless Health) for CoE residents. These rotations expanded primary care experiences and allowed for in-depth opportunities to care for the unique needs of veterans. Resident feedback was solicited through program evaluations, and career choices were tracked. RESULTS Eighty-five of 102 (83%) possible rotation evaluations from 2014 to 2017 were reviewed. Residents reported that CoEPCE rotations had a positive effect on their care of patients and career choice, and provided opportunities to interface with faculty role models. Seventy-five percent of Seattle VA CoE residents selected primary care careers compared to 36% of historical controls. CONCLUSIONS The CoEPCE rotation curriculum offers in-depth primary care training and may contribute to trainees maintaining interest in primary care careers.
Collapse
|
20
|
Kung A, Cheung T, Knox M, Willard-Grace R, Halpern J, Olayiwola JN, Gottlieb L. Capacity to Address Social Needs Affects Primary Care Clinician Burnout. Ann Fam Med 2019; 17:487-494. [PMID: 31712286 PMCID: PMC6846269 DOI: 10.1370/afm.2470] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 05/10/2019] [Accepted: 05/30/2019] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Primary care clinicians disproportionately report symptoms of burnout, threatening workforce sustainability and quality of care. Recent surveys report that these symptoms are greater when clinicians perceive fewer clinic resources to address patients' social needs. We undertook this study to better understand the relationship between burnout and clinic capacity to address social needs. METHODS We completed semistructured, in-person interviews and brief surveys with 29 primary care clinicians serving low-income populations. Interview and survey topics included burnout and clinic capacity to address social needs. We analyzed interviews using a modified grounded theory approach to qualitative research and used survey responses to contextualize our qualitative findings. RESULTS Four key themes emerged from the interview analyses: (1) burnout can affect how clinicians evaluate their clinic's resources to address social needs, with clinicians reporting high emotional exhaustion perceiving low efficacy even in when such resources are available; (2) unmet social needs affect practice by influencing clinic flow, treatment planning, and clinician emotional wellness; (3) social services embedded in primary care clinics buffer against burnout by increasing efficiency, restoring clinicians' medical roles, and improving morale; and (4) clinicians view clinic-level interventions to address patients' social needs as a necessary but insufficient strategy to address burnout. CONCLUSIONS Primary care clinicians described multiple pathways whereby increased clinic capacity to address patients' social needs mitigates burnout symptoms. These findings may inform burnout prevention strategies that strengthen the capacity to address patients' social needs in primary care clinical settings.
Collapse
Affiliation(s)
- Alina Kung
- University of California Berkeley-UCSF Joint Medical Program, Berkeley, California
| | | | - Margae Knox
- University of California San Francisco, Center for Excellence in Primary Care, San Francisco, California
| | - Rachel Willard-Grace
- University of California San Francisco, Center for Excellence in Primary Care, San Francisco, California
| | - Jodi Halpern
- University of California Berkeley-UCSF Joint Medical Program, Berkeley, California.,University of California Berkeley, School of Public Health, Berkeley, California
| | - J Nwando Olayiwola
- Department of Family Medicine, Ohio State University College of Medicine, Columbus, Ohio
| | - Laura Gottlieb
- University of California San Francisco, Department of Family and Community Medicine, San Francisco, California.,Social Interventions Research and Evaluation Network, San Francisco, California
| |
Collapse
|
21
|
Klein R. Delivering on the Promise: Exploring Training Characteristics and Graduate Career Pursuits of Primary Care Internal Medicine Residency Programs and Tracks. J Grad Med Educ 2019; 11:447-453. [PMID: 31440340 PMCID: PMC6699538 DOI: 10.4300/jgme-d-19-00010.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/20/2019] [Accepted: 06/10/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Specialized primary care internal medicine (PC IM) residency programs and tracks aim to provide dedicated PC training. How programs deliver this is unclear. OBJECTIVE We explored how PC IM programs and tracks provide ambulatory training. METHODS We conducted a cross-sectional survey from 2012 to 2013 of PC IM program and track leaders via a search of national databases and program websites. We reported PC IM curricular content, clinical experiences, and graduate career pursuits, and assessed correlation between career pursuits and curricular content and clinical experiences. RESULTS Forty-five of 70 (64%) identified PC IM programs and tracks completed the survey. PC IM programs provide a breadth of curricular content and clinical experiences, including a mean 22.8 weeks ambulatory training and a mean 69.4 continuity clinics per year. Of PC IM graduates within 5 years, 55.8% pursue PC or general internal medicine (GIM) careers and 23.1% pursue traditional subspecialty fellowship training. Curricular content and clinical experiences correlate weakly with career choices. PC IM graduates pursuing PC or GIM careers correlated with ambulatory rotation in women's health (correlation coefficient [rho] = 0.36, P = .034) and mental health (rho = 0.38, P = .023) and curricular content in teaching and medical education (rho = 0.35, P = .035). PC IM graduates pursuing subspecialty fellowship negatively correlated with curricular content in leadership and teams (rho = -0.48, P = .003) and ambulatory training time (rho = -0.38, P = .024). CONCLUSIONS PC IM programs and tracks largely deliver on the promise to provide PC training and education and produce graduates engaged in PC and GIM.
Collapse
|
22
|
Lyons AJ, Davids S, Fletcher KE. Response to Factors Affecting Resident Satisfaction in Continuity Clinic. J Gen Intern Med 2019; 34:1370. [PMID: 31011974 PMCID: PMC6667536 DOI: 10.1007/s11606-019-04988-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Amalia J Lyons
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan Davids
- Department of Internal Medicine, Clement J. Zablocki VAMC and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathlyn E Fletcher
- Department of Internal Medicine, Clement J. Zablocki VAMC and the Medical College of Wisconsin, Milwaukee, WI, USA.
| |
Collapse
|
23
|
O'Rourke P, Tseng E, Chacko K, Shalaby M, Cioletti A, Wright S. A National Survey of Internal Medicine Primary Care Residency Program Directors. J Gen Intern Med 2019; 34:1207-1212. [PMID: 30963438 PMCID: PMC6614222 DOI: 10.1007/s11606-019-04984-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 12/11/2018] [Accepted: 03/05/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The United States is facing a primary care physician shortage. Internal medicine (IM) primary care residency programs have expanded substantially in the past several decades, but there is a paucity of literature on their characteristics and graduate outcomes. OBJECTIVE We aimed to characterize the current US IM primary care residency landscape, assess graduate outcomes, and identify unique programmatic or curricular factors that may be associated with a high proportion of graduates pursuing primary care careers. DESIGN Cross-sectional study PARTICIPANTS: Seventy out of 100 (70%) IM primary care program directors completed the survey. MAIN MEASURES Descriptive analyses of program characteristics, educational curricula, clinical training experiences, and graduate outcomes were performed. Bivariate and multivariate logistic regression analyses were used to determine the association between ≥ 50% of graduates in 2016 and 2017 entering a primary care career and program characteristics, educational curricula, and clinical training experiences. KEY RESULTS Over half of IM primary care program graduates in 2016 and 2017 pursued a primary care career upon residency graduation. The majority of program, curricular, and clinical training factors assessed were not associated with programs that have a majority of their graduates pursuing a primary care career path. However, programs with a majority of program graduates entering a primary care career were less likely to have X + Y scheduling compared to the other programs. CONCLUSIONS IM primary care residency programs are generally succeeding in their mission in that the majority of graduates are heading into primary care careers.
Collapse
Affiliation(s)
- Paul O'Rourke
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.
| | - Eva Tseng
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Chacko
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marc Shalaby
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Anne Cioletti
- Division of Primary Care and Value-Based Health, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Scott Wright
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| |
Collapse
|
24
|
Roy P, Jackson AH, Baxter J, Brett B, Winter M, Hardesty I, Alford DP. Utilizing a Faculty Development Program to Promote Safer Opioid Prescribing for Chronic Pain in Internal Medicine Resident Practices. PAIN MEDICINE 2019; 20:707-716. [PMID: 30649546 DOI: 10.1093/pm/pny292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To implement a skills-based faculty development program (FDP) to improve Internal Medicine faculty's clinical skills and resident teaching about safe opioid prescribing. DESIGN An FDP for Internal Medicine attendings that included a one-hour didactic presentation followed immediately by an Objective Structured Clinical Examination (OSCE) that focused on assessing and managing opioid misuse risk, opioid treatment outcomes (benefits and harms), and aberrant opioid use behaviors. The evaluation compared pre- and three-months-post-FDP changes in faculty's safe opioid prescribing knowledge, attitudes, confidence (clinical and teaching), and self-reported resident teaching. RESULTS The 25 Internal Medicine faculty participants had a mean of 13 years in clinical practice, including 10 years precepting residents. During the three months post-FDP, faculty treated a mean of 22 patients with chronic pain on long-term opioids and precepted a mean of seven residents caring for patients on long-term opioids. At three months post-FDP, there were significant improvements in correct responses to knowledge questions (68% to 79% P = 0.008), "high-level" confidence in safer opioid prescribing clinical practice (43.5% to 82.6% P = 0.007) and resident teaching (45.8% to 83.3%, P = 0.007), and improvements in alignment of desired attitudes toward safer opioid prescribing. There were nonsignificant increases in self-reported safe opioid prescribing resident teaching. CONCLUSIONS A skills-based faculty development program that includes a lecture followed by an OSCE can improve Internal Medicine faculty safe opioid prescribing knowledge, attitudes, and clinical and teaching confidence. Improving resident teaching may require additional training in safe opioid prescribing teaching skills.
Collapse
Affiliation(s)
- Payel Roy
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Angela H Jackson
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Jeffrey Baxter
- Department of Family Medicine, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Belle Brett
- Brett Consulting Group, Somerville, Massachusetts
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Ilana Hardesty
- The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Daniel P Alford
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.,The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
25
|
Forman JH, Robinson CH, Krein SL. Striving toward team-based continuity: provision of same-day access and continuity in academic primary care clinics. BMC Health Serv Res 2019; 19:145. [PMID: 30832649 PMCID: PMC6399842 DOI: 10.1186/s12913-019-3943-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/01/2019] [Indexed: 12/04/2022] Open
Abstract
Background An important goal of the patient-centered medical home is increasing timely access for urgent needs, while maintaining continuity. In academic primary care clinics, meeting this goal, along with training medical residents and associated professionals, is challenging. Methods The aim of this study was to understand how academic primary care clinics provide continuity to patients requesting same-day access and identify factors that may affect site-level success. We conducted qualitative interviews from December 2013–October 2014 with primary care leadership involved with residency programs at 19 Veterans Health Administration academically-affiliated medical centers. Interview recordings were transcribed verbatim. To analyze the data, we created comprehensive, structured transcript summaries for each site. Site summaries were then entered into NVivo 10 software and coded by main categories to facilitate within-case and cross-case analyses. Themes and patterns across sites were identified using matrix analysis. Results Interviewees found it challenging to provide continuity for same-day in-person visits. Most sites took a team-based approach to ensure continuity and provide coverage for same-day access, notably using NPs, PAs, and RNs in their coverage algorithms. Further, they reported several adaptations that increased multiple types of continuity for walk-in patients, urgent care between in-person visits, and follow-up care. While this study focused on longitudinal continuity, both by individual PCPs or by a team of professionals, informational continuity and continuity of supervision, as well as, to a lesser extent, relational and management continuity, were also addressed in our interviews. Finally, most interviewees reported clinic intention to provide patient-centered, team-based care and a robust educational experience for trainees, and endeavored to structure their clinics in ways that align these two missions. Conclusions In contending with the tension between providing continuity and educating new clinicians, clinics have re-conceptualized continuity as team-based, creating alternative strategies to same-day visits with a usual provider, coupled with communication strategies. Understanding the effect of these strategies on different types of continuity as well as patient experience and outcomes are key next steps in the further development and dissemination of effective models for improving continuity and the transition to team-based care in the academic clinic setting. Electronic supplementary material The online version of this article (10.1186/s12913-019-3943-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jane H Forman
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, UM North Campus Research Complex, 2800 Plymouth Road, Building 16, 3rd floor, Ann Arbor, MI, 48109-2800, USA.
| | - Claire H Robinson
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, UM North Campus Research Complex, 2800 Plymouth Road, Building 16, 3rd floor, Ann Arbor, MI, 48109-2800, USA
| | - Sarah L Krein
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, UM North Campus Research Complex, 2800 Plymouth Road, Building 16, 3rd floor, Ann Arbor, MI, 48109-2800, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
26
|
Byhoff E, Freund KM, Garg A. Accelerating the Implementation of Social Determinants of Health Interventions in Internal Medicine. J Gen Intern Med 2018; 33:223-225. [PMID: 29188543 PMCID: PMC5789112 DOI: 10.1007/s11606-017-4230-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/27/2017] [Accepted: 11/03/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Elena Byhoff
- Tufts Medical Center, Boston, MA, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| | - Karen M Freund
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Arvin Garg
- Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
27
|
Chasin JL. Capsule Commentary on Long et al., Why Aren't More Primary Care Residents Going Into Primary Care? A Qualitative Study. J Gen Intern Med 2016; 31:1503. [PMID: 27730486 PMCID: PMC5130969 DOI: 10.1007/s11606-016-3881-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Judith Lauren Chasin
- Family Physician, Urgent Care Medicine, St. Luke's Health System, Boise, ID, USA.
| |
Collapse
|
28
|
Rosenblum MJ. Capsule Commentary on Thorp et al., Implementation of 2011 Duty Hours Regulations Through a Workload Reduction Strategy and Impact on Residency Training. J Gen Intern Med 2016; 31:1506. [PMID: 27761770 PMCID: PMC5130963 DOI: 10.1007/s11606-016-3863-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Michael J Rosenblum
- Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA.
| |
Collapse
|