Feeling inadequate: Residents' stress and learning at primary care clinics in the United States

Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees

BACKGROUND

A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure.

METHODS

This retrospective cohort study included all patient visits from January 1, 2018, to December 31, 2021, at two academic medical center-based primary care practices where residents and faculty practice in the same setting. The primary outcome was prevalence of failure to close the loop for (1) dermatology referrals, (2) colonoscopy, and (3) cardiac stress testing. The primary predictor was resident vs. faculty status of the ordering provider. The authors present an unadjusted analysis and the results of a multivariable logistic regression analysis incorporating all patient factors to determine their association with loop closure.

RESULTS

Of 12,282 orders for referrals and tests for the three studied areas, 1,929 (15.7%) were ordered by a resident physician. Of resident orders for all three tests, 52.9% were completed within the designated time vs. 58.4% for orders placed by attending physicians (p < 0.01). In an unadjusted analysis by test type, a similar trend was seen for colonoscopy (51.4% completion rate for residents vs. 57.5% for attending physicians, p < 0.01) and for cardiac stress testing (55.7% completion rate for residents vs. 61.2% for attending physicians), though a difference was not seen for dermatology referrals (64.2% completion rate for residents vs. 63.7% for attending physicians). In an adjusted analysis, patients with resident orders were less likely than attendings to close the loop for all test types combined (odds ratio 0.88, 95% confidence interval 0.79-0.98), with low rates of test completion for both physician groups.

CONCLUSION

Loop closure for three diagnostic interventions was low for patients in both faculty and resident primary care clinics, with lower loop closure rates in resident clinics. Failure to close diagnostic loops presents a safety challenge in primary care and is of particular concern for training programs.

Perspectives on Training and Working in the VHA: Implications for Primary Care Physician Recruitment and Retention

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.

Implementing Clinic First Guiding Actions Across 4 Family Medicine Residency Clinics

PROBLEM

Family medicine faculty and residents have observed that continuity clinic is often unsatisfying, attributed to a lack of patient and team continuity and erratic clinic schedules pieced together after the prioritization of hospital service and rotation schedules.

APPROACH

In 2019, a 3-year Clinic First project, called Clinic as Curriculum (CaC), was launched across the 4 family medicine residencies of the Department of Family Medicine and Community Health, University of Minnesota Medical School. The department began publishing quarterly CaC dashboard data. Each clinic completed a baseline assessment of their performance on the 13 Building Blocks of High-Performing Primary Care. Using their baseline data, each clinic identified which block or blocks, in addition to the blocks on continuity of care and resident scheduling, to focus on. The plan is to collaboratively implement the overall and local goals using dashboard data and iterative process improvement over 3 years.

OUTCOMES

At baseline, clinics functioned quite well with respect to the 13 building blocks, but CaC dashboard data varied across the 4 clinics, with large variation between clinics on how frequently faculty were scheduled in the clinic and the proportion of total clinic visits seen by faculty. Resident continuity rates were low (range, 38%-47%). Level loading (consistent physician availability to meet patient demand) rates ranged from 1 to 11 days a month. Regarding resident schedules, 2 programs are moving from 4-week to 2-week inpatient blocks, and 2 programs are exploring longitudinal scheduling. One clinic will assign faculty and residents to specific clinic days. Two clinics are implementing microteams of 1 faculty and 3-4 residents.

NEXT STEPS

The authors plan to analyze the dashboard data longitudinally; explore microteams, team continuity, and team scheduling adherence; and develop and implement resident scheduling changes over the next 3 years.

Hirshfield L. The Resurgence of Medical Education in Sociology: A Return to Our Roots and an Agenda for the Future

From 1940 to 1980, studies of medical education were foundational to sociology, but attention shifted away from medical training in the late 1980s. Recently, there has been a marked return to this once pivotal topic, reflecting new questions and stakes. This article traces this resurgence by reviewing recent substantive research trends and setting the agenda for future research. We summarize four current research foci that reflect and critically map onto earlier projects in this subfield while driving theoretical development elsewhere in the larger discipline: (1) professional socialization, (2) knowledge regimes, (3) stratification within the profession, and (4) sociology of the field of medical education. We then offer six potential future directions where more research is needed: (1) inequalities in medical education, (2) socialization across the life course and new institutional forms of gatekeeping, (3) provider well-being, (4) globalization, (5) medical education as knowledge-based work, and (6) effects of the COVID-19 pandemic.

A Mixed Methods Study of Change Processes Enabling Effective Transition to Team-Based Care

Team-based care is considered central to achieving value in primary care, yet results of large-scale primary care transformation initiatives have been mixed. We explore how underlying change processes influence the effectiveness of transition to team-based care. We studied 12 academically affiliated primary care practices participating in a learning collaborative, using longitudinal staff survey data to measure progress toward team-based care and qualitative interviews with practice staff to understand practice transformation. Transformation efforts focused on team formation and capacity building for quality improvement. Using thematic analysis, we explored types of change processes undertaken and the relationship between change processes and effective team-based care. We identified three prototypical approaches to change: pursuing functional and cultural change processes, functional only, and cultural only. Practice sites prioritizing both change processes formed the most effective teams: simultaneous functional and cultural change spurred a mutually reinforcing virtuous cycle. We describe implications for research, practice, and policy.

Exploring How Personal, Social, and Institutional Characteristics Contribute to Geriatric Medicine Subspecialty Decisions: A Qualitative Study of Trainees' Perceptions

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.

Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates

Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices’ successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

Intentional or Not: Teamwork Learning at Primary Care Clinics

BACKGROUND AND OBJECTIVES

Primary care teamwork has been shown to increase satisfaction and decrease stress for physicians but the impact of outpatient teamwork for primary care residents' learning has not been described. This study aimed to understand the role of teamwork in residents' learning during and after the establishment of teams.

METHODS

Interviews with 37 primary care residents addressed their experiences at outpatient clinic, including their perceptions about whether team-based care affected their educational experience. Using qualitative thematic analysis, transcripts were coded to identify themes about teamwork and learning, both positive and negative.

RESULTS

Residents described learning both about and through teamwork at continuity clinic, despite variation in the speed and extent of initial integration into teams. As residents learned how to work on a team, they realized the importance of face-to-face time together and trusting one another. Team members also taught residents about the clinical system and social aspects of patient care, as well as some procedural skills, which led them to understand how teamwork can improve patient care and efficiency. Finally, residents learned, through both optimal and suboptimal first-hand team experiences, to see team-based care as a model for future primary care practice.

CONCLUSIONS

While integrating residents into primary care teams, educators should consider the potential value of teamwork as an intentional learning method. Team members, beyond the preceptor, can offer valuable instruction, and team-based workplace learning prepares residents to use teamwork to optimize care for patients.

Disparities in Quality of Primary Care by Resident and Staff Physicians: Is There a Conflict Between Training and Equity?

BACKGROUND

Outpatient primary care experience is vital to internal medicine resident training but may impact quality and equity of care delivered in practices that include resident physicians. Understanding whether quality differences exist among resident and staff primary care physicians (PCPs) may present an opportunity to address health disparities within academic medical centers.

OBJECTIVE

To determine whether there are differences in the quality of primary care provided by resident PCPs compared to staff PCPs.

DESIGN

A retrospective cohort study with a propensity-matched analysis.

PARTICIPANTS

143,274 patients, including 10,870 patients managed by resident PCPs, seen in 16 primary care practices affiliated with an academic medical center.

MAIN MEASURES

Guideline-concordant chronic disease management of diabetes (HbA1c, LDL) and coronary artery disease (LDL), preventive breast, cervical, and colorectal cancer screening, and resource utilization measures including emergency department (ED) visits, hospitalizations, high-cost imaging, and patient-reported health experience.

KEY RESULTS

At baseline, there were significant differences in sociodemographic and clinical characteristics between resident and staff physician patients. Resident patients were less likely to achieve chronic disease and preventive cancer screening outcome measures including LDL at goal (adjusted OR [aOR] 0.77 [95% CI 0.65, 0.92]) for patients with coronary artery disease; HbA1c at goal (aOR 0.73 [95% CI 0.62, 0.85]) for patients with diabetes; breast (aOR 0.56 [95% CI 0.49, 0.63]), cervical (aOR 0.66 [95% CI 0.60, 0.74]), and colorectal (aOR 0.72 [95% CI 0.65, 0.79] cancer screening. Additionally, resident patients had higher rates of ED visits and hospitalizations but lower rates of high-cost imaging. Resident patients reported lower rates of satisfaction with certain access to care and communication measures. Similar outcomes were noted in propensity-matched sensitivity analyses.

CONCLUSION

After controlling for differences in sociodemographic and clinical factors, resident patients were less likely to achieve chronic disease and preventive cancer screening outcomes compared to staff patients. Further efforts to address ambulatory trainee education and primary care quality along with novel approaches to the management of the disproportionately disadvantaged resident patient panels are needed.

A Decade of Teaching and Learning in Internal Medicine Ambulatory Education: A Scoping Review

BACKGROUND

Ambulatory training in internal medicine residency programs has historically been considered less robust than inpatient-focused training, which prompted a 2009 revision of the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements in Internal Medicine. This revision was intended to create a balance between inpatient and outpatient training standards and to spur innovation in the ambulatory setting.

OBJECTIVE

We explored innovations in ambulatory education in internal medicine residency programs since the 2009 revision of the ACGME Program Requirements in Internal Medicine.

METHODS

The authors conducted a scoping review of the literature from 2008 to 2017, searching PubMed, ERIC, and Scopus databases. Articles related to improving educational quality of ambulatory components of US-based internal medicine residency programs were eligible for inclusion. Articles were screened for relevance and theme categorization and then divided into 6 themes: clinic redesign, curriculum development, evaluating resident practice/performance, teaching methods, program evaluation, and faculty development. Once a theme was assigned, data extraction and quality assessment using the Medical Education Research Study Quality Instrument (MERSQI) score were completed.

RESULTS

A total of 967 potentially relevant articles were discovered; of those, 182 were deemed relevant and underwent full review. Most articles fell into curriculum development and clinic redesign themes. The majority of included studies were from a single institution, used nonstandardized tools, and assessed outcomes at the satisfaction or knowledge/attitude/skills levels. Few studies showed behavioral changes or patient-level outcomes.

CONCLUSIONS

While a rich diversity of educational innovations have occurred since the 2009 revision of the ACGME Program Requirements in Internal Medicine, there is a significant need for multi-institution studies and higher-level assessment.

Provider Perspectives of Medication Complexity in Home Health Care: A Qualitative Secondary Data Analysis

A primary service provided by home care is medication management. Issues with medication management at home place older adults at high risk for hospital admission, readmission, and adverse events. This study sought to understand medication management challenges from the home care provider perspective. A qualitative secondary data analysis approach was used to analyze program evaluation interview data from an interprofessional educational intervention study designed to decrease medication complexity in older urban adults receiving home care. Directed and summative content analysis approaches were used to analyze data from 90 clinician and student participants. Medication safety issues along with provider–provider communication problems were central themes with medication complexity. Fragmented care coordination contributed to medication management complexity. Patient-, provider-, and system-level factors influencing medication complexity and management were identified as contributing to both communication and coordination challenges.

Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients

IMPORTANCE

Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions.

OBJECTIVE

To evaluate the association of establishing team-based primary care with patient health care use and costs.

DESIGN, SETTING, AND PARTICIPANTS

We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018.

EXPOSURES

Practices participated in a 4-year learning collaborative that created and supported team-based primary care.

MAIN OUTCOMES AND MEASURES

Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care.

RESULTS

Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n = 51 155 [37.0%] vs n = 186 954 [46.6%]), more participants younger than 18 years (n = 337 931 [27.5%] vs n = 74 691 [18.6%]), higher Medicaid enrollment (n = 39 541 [28.6%] vs n = 81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P < .001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P = .03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P = .007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P = .009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P < .001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P = .003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P = .02).

CONCLUSIONS AND RELEVANCE

While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.