Putting residents in the office: an effective method to teach the systems-based practice competency

A Systematic Review on the Effectiveness of Systems-Based Practice Curricula in Health Professions Education

This systematic review aims to evaluate the effectiveness of systems-based practice (SBP) curricula from the perspective of health professions students and workers. A total of 8468 citations were sourced from six electronic databases and manual searches conducted independently by two researchers, of which 44 studies were eventually included. A meta-analysis using a random effects model and a meta-synthesis using the thematic synthesis approach were conducted. Most studies targeted medical students, residents, and resident physicians from various clinical specialties. Almost half of all studies focused on didactic or knowledge-based interventions to teach SBP. About a third of all studies measured non-self-evaluated knowledge change, clinical abilities, and clinical outcomes. Both meta-analysis and meta-synthesis results revealed positive outcomes of increased knowledge of SBP, increased recognition of SBP as a core competency in one's profession, and increased application of SBP knowledge in one's profession. Meta-synthesis results also revealed negative outcomes at the institutional and teacher/health professions level. This review highlights the importance of SBP education and supports the effectiveness of SBP curricula. There is a need to address the negative outcomes at the institutional and teacher/health professions level. Moreover, future studies could investigate the integration of self-assessment outcomes with comparison to some external standard.

Implementation of a Business of Healthcare Curriculum for General Surgery Residents

OBJECTIVE

To better prepare general surgery residents for handling the business aspects of healthcare, this project evaluation reports on the implementation of a business of healthcare curriculum (BHC) in a general surgery residency program. We evaluated (pre and post curriculum) self-perceived knowledge and attitudes toward common business topics.

DESIGN

General surgery residents were administered a 13-item survey (7 Likert-type and 3 open-ended items assessing self-perceived knowledge and attitudes toward BHC, and 3 demographic questions) prior to the start of the curriculum. The curriculum was comprised of four core sessions, which included didactic lectures and group projects, including the creation of a business plan. At the conclusion of the curriculum, a post-test with the same items was administered. A total of 21 residents completed both the pre and post-tests.

SETTING

The BHC was a mandatory part of the general surgery residency program and was conducted in Honolulu, Hawaii (University of Hawaii at Manoa).

PARTICIPANTS

All general surgery residents, PGY-1 to PGY-5, were required to participate in the curriculum.

RESULTS

Statistically significant increases in resident knowledge were found overall and specifically for healthcare reform legislation, differences between practice settings, financial matters, contracting and coding and billing for services. Additionally, responses to open-ended questions showed that residents had a positive attitude toward the curriculum and found it useful.

CONCLUSIONS

General surgery residency programs can successfully create an impactful business of healthcare curriculum with minimal cost if volunteers and existing resources are utilized.

A Qualitative Study of the Barriers and Benefits to Resident Education in Ambulatory Surgical Centers

OBJECTIVE

As Ambulatory Surgical Centers (ASCs) become more common in academic medical centers, large hospital systems must determine how to shift resident education from inpatient to outpatient surgical centers. This study aims to define stakeholders' views regarding the integration of surgical residents into ASCs.

DESIGN

Long-form interviews lasting 30 to 60 minutes were conducted. Interviews were hand-transcribed and analyzed by qualitative analysis to determine benefits of learning in ASCs for residents, challenges that arise from integrating residents, and recommendations to improve resident incorporation.

SETTING

Interviews were conducted using a video conferencing platform.

PARTICIPANTS

Residency program directors, attending surgeons, graduate medical learners, and a nursing manager were interviewed. Twenty-one total interviews were conducted, representing ten different departments.

RESULTS

Stakeholders agreed that residents benefit from being placed in ASCs because the fast, surgical pace allows the residents to engage in more cases. However, different stakeholders highlighted different challenges, all centered around the notion of inter-stakeholder conflict due to conflicting priorities among residents, attending physicians, and administration. Likewise, recommendations differed by stakeholder group-faculty members sought more defined learning objectives and enhanced communication, whereas residents desired that ambulatory surgical time be more structured.

CONCLUSIONS

Despite the pressures of rapid case turnover, stakeholders agreed that there are many benefits to resident education in ASCs. Findings related to challenges and recommendations support the need to strengthen communication between stakeholder groups and better plan for resident integration into ASCs.

Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education

Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.

Coding Education in Residency and in Practice Improves Accuracy of Coding in Orthopedic Surgery

The goal of training in orthopedic residency is to produce surgeons who are proficient in all aspects of the practice of orthopedic surgery; however, most residents receive either inadequate or no training in medical coding. The purpose of this study was to determine how well orthopedic residents code when compared with practicing surgeons and to identify whether coding education improves accuracy in medical coding. A mock coding survey was developed using commonly encountered orthopedic clinical scenarios. The survey was distributed to orthopedic trainees post-graduate years (PGY) 1 to 6 at 2 training programs and to attending surgeons. Results were analyzed in 3 groups: junior residents (PGY 1-3), senior residents (PGY 4-6), and attending surgeons. Overall and subcategory scores of (1) type of visit, (2) modifiers, (3) Evaluation and Management (E/M), and (4) Current Procedural Terminology code identification were recorded. Participants were also asked if they had ever received various forms of coding education. Sixty-seven total participants were enrolled, including 28 junior residents, 24 senior residents, and 15 attendings. Practicing surgeons performed significantly better than both senior (P<.027) and junior (P<.001) residents in all categories, with a mean overall correct response rate of 72.8%, 51.0%, and 47.4%, respectively. Any form of coding education was associated with a significantly improved overall score for residents (P=.013) and a nonsignificant increase for attending surgeons (P=.390). This study demonstrates that residents performed poorly when identifying proper billing codes for common procedures and encounters in orthopedic surgery. Further, those participants who received coding education did better than those who did not. [Orthopedics. 2020;43(6):380-383.].

Development and Implementation of a Nonclinical Professional Development Rotation

Residency programs often struggle with strategies to formally teach leadership and communications skills. To provide a catalyst for professional development, Vanderbilt University Medical Center implemented a curriculum aimed at addressing this gap. Starting in 2014, the authors implemented a 2-week professional development rotation for first-year anesthesiology residents. Experts provided a series of didactic and experiential sessions focused on various professional development topics. Outcomes were assessed using pre- and postrotation surveys. Sixty-nine residents completed the rotation over a 4-year period, and 82% (54 of 66) strongly agreed that nonclinical professional development should be a component of training.

Implementation of a medical coding curriculum for surgery residents

BACKGROUND

Medical coding knowledge is important for practice. We hypothesized that general surgery residents lack confidence in medical coding (MC) and that implementation of focused didactics would increase resident confidence and knowledge.

METHODS

A MC curriculum was delivered to general surgery residents covering domains of the global procedural period (GPP), evaluation and management (E/M) coding, and hospital payment and quality metrics (HPQM). A 21-question survey was developed to assess resident comfort coding knowledge. Efficacy of the MC curriculum was measured by anonymous paper pre-test and post-test surveys.

RESULTS

Pre-test (n = 50) findings revealed that residents were uncomfortable with MC. Following three MC lectures, the post-test (n = 24) demonstrated significant increases in resident comfort with MC (p < 0.001) and resident performance on domains of GPP (p = 0.014), E/M (p < 0.001), and HQPM (p = 0.025).

CONCLUSIONS

Residents feel uncomfortable with MC without formal education. This study supports a focused curriculum to prepare residents for practice.

A Systems-Based Practice Curriculum in Orthopaedics: Successes and Challenges Moving Forward

BACKGROUND

Teaching and assessment of the systems-based practice competency have been a challenge for many educators in graduate medical education. Previous research done at our institution demonstrated a marked inconsistency across institutions in educational content, methods of delivery, and performance assessment. As a result, we developed a 2-week health systems curriculum for orthopaedic surgery residents.

METHODS

A 2-week health systems rotation was developed during which postgraduate year (PGY)-1 residents were excused from their normal clinical duties. Residents followed patients as observers of the health-care system, challenged to view health care through the eyes of the patient and to identify what could be done individually and collectively to provide a better and safer experience. Additional learning experiences were designed on the basis of our literature review. At the end of the rotation, residents discussed and provided a written summary of their experiences and completed an anonymous evaluation. Using a Likert scale (1 to 10), residents were asked if the experience was educational and whether it was it additive to their undergraduate medical education for each of the 9 educational areas.

RESULTS

The mean responses for all 9 educational areas were 8.2 for whether the experience was educational and 8.3 for whether it was it additive to participants' undergraduate medical education. Feedback from residents indicated that they found the course very helpful and that it inspired them to consider how they could "create overdue and necessary changes in our health-care system."

CONCLUSIONS

Our health systems rotation in PGY-1 has been a valuable learning experience for the residents and has created a foundation on which to build in subsequent years of residency.

Enhancing Confidence in Graduating General Surgery Residents: Establishing a Chief Surgery Resident Service at an Independent Academic Medical Center

OBJECTIVE

Providing opportunities for autonomy to enhance the development of independence and confidence during surgery residency remains among the greatest challenges of the current training paradigm. The objective of this study was to evaluate the implementation and outcomes of a chief resident service (CRS).

DESIGN

A CRS was designed with operative, call and office responsibilities. Supervision and evaluation were consistent with institutional guidelines. CRS operative logs from 2011 to 2014 were compared with logs from the participants' first year in practice. Select procedures were compared and evaluations were reviewed. Residency graduates' satisfaction with the CRS was evaluated.

SETTING

Independent academic medical center.

PARTICIPANTS

Nine general surgery residency graduates with one complete year in practice.

RESULTS

Nine residents completed CRS rotations and submitted case logs. Median total case volume was 1101 (994-1311) during the 5-year residency, 92 (20-149) during CRS and 299 (99-784) during the first year in practice. Median case volumes for selected procedures for the entire 5-year residency, CRS, and first year of practice were: 93 (66-97), 7 (3-16), and 9 (1-26) laparoscopic appendectomies; 146 (120-157), 24 (3-32), and 34 (15-112) laparoscopic cholecystectomies; 81 (51-94), 1 (1-4), and 3 (0-8) ileocolectomies; 57 (35-86), 4 (0-9), and 8 (2-34) ventral/incisional hernia repairs; 102 (87-137), 12 (3-16), and 13 (3-86) inguinal hernia repairs. Graduates reported that the CRS experience was very beneficial to their current practice. Annual program reviews emphasized the CRS as a major strength of our residency.

CONCLUSIONS

Creation of a CRS to increase resident autonomy and provide continuity of patient care with appropriate faculty supervision was successful. Case mix and volumes provided an opportunity for independent operative and clinical experience during residency which realistically paralleled graduates' first year of practice.

Billing by residents and attending physicians in family medicine: the effects of the provider, patient, and visit factors

BACKGROUND

Medical billing and coding are critical components of residency programs since they determine the revenues and vitality of residencies. It has been suggested that residents are less likely to bill higher evaluation and management (E/M) codes compared with attending physicians. The purpose of this study is to assess the variation in billing patterns between residents and attending physicians, considering provider, patient, and visit characteristics.

METHOD

A retrospective cohort study of all established outpatient visits at a family medicine residency clinic over a 5-year period was performed. We employed the logistic regression methodology to identify residents' and attending physicians' variations in coding E/M service levels. We also employed Poisson regression to test the sensitivity of our result.

RESULTS

Between January 5, 2009 and September 25, 2015, 98,601 visits to 116 residents and 18 attending physicians were reviewed. After adjusting for provider, patient, and visit characteristics, residents billed higher E/M codes less often compared with attending physicians for comparable visits. In comparison with attending physicians, the odds ratios for billing higher E/M codes were 0.58 (p = 0.01), 0.56 (p = 0.01), and 0.63 (p = 0.01) for the third, second, and first years of postgraduate training, respectively. In addition to the main factors of patient age, medical conditions, and number of addressed problems, the gender of the provider was also implicated in the billing variations.

CONCLUSION

Residents are less likely to bill higher E/M codes than attending physicians are for similar visits. While these variations are known to contribute to lost revenues, further studies are required to explore their effect on patient care in relation to attendings' direct involvement in higher E/M-coded versus their indirect involvement in lower E/M-coded visits.

Training residents to be factually accurate and articulate: A case study using foetal heart rate monitoring nomenclature

Careful communication between members of the obstetric team about intrapartum foetal heart rate is critical for clinical management and patient safety. This study evaluated the benefits of two testing modalities in assessing resident physician knowledge of the 2008 NICHD nomenclature. Multiple-choice (MC) and short-answer (SA) examinations were administered to Obstetrics and Gynecology resident physicians before an educational intervention and then immediately after the training, at 6 months and at 12 months. Test scores on both the MC and the SA examinations improved after the training session. The improvement was sustained over the course of the study. Residents performed higher on the MC examination than on the SA test. This study suggests that formalised teaching in foetal heart rate monitoring improves resident physician knowledge of the NICHD nomenclature and that SA examinations may better discriminate between residents who are and are not able to accurately articulate foetal heart rate monitoring terminology.

Resident Preparation for Careers in General Surgery: A Survey of Program Directors

OBJECTIVE

The number of general surgery (GS) residency graduates who choose GS practice has diminished as the popularity of postresidency fellowships has dramatically increased over the past several decades. This study was designed to document current methods of GS preparation during surgery residency and to determine characteristics of programs that produce more graduates who pursue GS practice.

DESIGN

An email survey was sent by the American Board of Surgery General Surgery Advisory Committee to program directors of all GS residencies. Program demographic information was procured from the American Board of Surgery database and linked to survey results. Multiple regression was used to predict postresidency choices of graduates.

SETTING

Totally, 252 US allopathic surgical residencies.

PARTICIPANTS

Totally, 171 residency program directors (68% response rate).

RESULTS

The proportion of programs using an emergency/acute care surgery rotation at the main teaching hospital to teach GS increased from 63% in 2003 to 83% in 2014. An autonomous GS outpatient experience was offered in 38% of programs. Practice management curricula were offered in 28% of programs. Institutions with fewer postresidency fellowships (p < 0.003) and fewer surgical specialty residencies (p < 0.036) had a greater percentage of graduates who pursued GS practice. The addition of each fellowship at an institution was associated with a 2% decrease in the number of graduates pursuing GS practice. Residency size was not associated with predilection for fellowship selection and there was no difference between university and independent residencies vis-a-vis the proportion selecting fellowship vs GS practice.

CONCLUSIONS

Practice management principles and autonomous GS outpatient clinic experiences are offered in a minority of programs. Graduates of programs in institutions with fewer surgery fellowships and residencies are more likely to pursue GS practice. Increased number of postresidency fellowships and specialty residencies may be associated with fewer GS rotations and fewer GS mentors. Further study of these relationships seems warranted.