What Makes the "Perfect" Inpatient Consultation? A Qualitative Analysis of Resident and Fellow Perspectives

We've Got a New One-Exploring the Resident-Fellow New Admission Interaction and Opportunities for Enhancing Motivation

OBJECTIVE

To characterize the phases of a new admission interaction between collaborating pediatric residents and fellows; to explore trainee perspectives on motivating and demotivating qualities of that interaction; and to identify behaviors that lead to an optimal new admission interaction.

METHODS

The authors used modified grounded theory with experiential learning theory and self-determination theory as sensitizing concepts to conduct 6 focus groups and journey mapping at Stanford Children's Health from January to March 2021. The sessions were audio-recorded and transcribed verbatim. Two authors independently coded the transcripts and developed categories and themes using constant comparison, while a third author reviewed these findings. The qualitative data were triangulated with surveys and journey mapping data and conceptualized into a model of trainee motivation during the new admission interaction. They outlined an optimal new admission interaction using behaviors consistently described by participants as motivating.

RESULTS

Developing inter-trainee trust and educational buy-in is essential for both residents and fellows to feel intrinsically motivated and engaged during a new admission. Residents need to feel autonomous, competent, and related to the team in order to develop trust and buy-in. Fellows require assurance of patient safety to develop trust and a sense of self-efficacy in fostering resident growth to develop buy-in. Lack of trust or buy-in from either party leads to a cycle of trainee disengagement.

CONCLUSIONS

Trainee motivation and engagement with patient care can be impacted by discreet, modifiable behavior by their fellow or resident counterpart, which may help improve the quality of care delivered.

Rethinking the consultation paradigm: Validity evidence for a new framework, a multimethods study

BACKGROUND

In-hospital consultation is essential for patient care. We previously proposed a framework of seven specific consultation types to classify consult requests to improve communication, workflow, and provider satisfaction.

METHODS

This multimethods study's aim was to evaluate the applicability of the consult classification framework to real internal medicine (IM) consults. We sought validity evidence using Kane's validity model with focus groups and classifying consult requests from five IM specialties. Participants attended five 1 h semi-structured focus groups that were recorded, transcribed, and coded for thematic saturation. For each specialty, three specialists and three hospitalists categorized 100 (total 500) random anonymized consult requests. The primary outcome was concordance in the classification of consult requests, defined as the sum of partial concordance and perfect concordance, where respectively 4-5/6 and 6/6 participants classified a consult in the same category. We used χ2 tests to compare concordance rates across specialties and between specialists and hospitalists.

RESULTS

Five major themes were identified in the qualitative analysis of the focus groups: (1) consult question, (2) interpersonal interactions, (3) value, (4) miscommunication, (5) consult framework application, barriers, and iterative development. In the quantitative analysis, the overall concordance rate was 88.8% (95% confidence interval [CI]: 85.7-91.4), and perfect concordance was 46.6% (95% CI: 42.2-51.1). Concordance differed significantly between hospitalists and specialists overall (p = .01), with a higher proportion of hospitalists having perfect concordance compared to specialists (67.2% vs. 57.8%, p = .002).

CONCLUSIONS

The consult classification framework was found to be applicable to consults from five different IM specialties, and could improve communication and education.

Relevance, quick hits, and vibe: Features of meaningful teaching and learning during trainee consult interactions

BACKGROUND

Consults are increasingly frequent in inpatient pediatric services. Consult interactions between trainees provide a rich opportunity for teaching and learning. What constitutes meaningful teaching interactions with trainees has not been described.

OBJECTIVE

Explore how consulting fellows and residents define "meaningful teaching interactions" associated with inpatient consult interactions.

METHODS

Four focus groups were conducted with 21 pediatric trainees (11 subspecialty fellows and 10 residents) at one institution. Transcriptions were analyzed using thematic analysis to inductively create categories and themes.

RESULTS

Five factors define meaningful teaching interactions: (1) Relevance; (2) Quick Hits; (3) Vibe; (4) Face-to-face Interactions; and (5) Timing and Busyness. Meaningful content was described as relevant to current or future patient care. Residents valued content that would enable them to explain the reasoning behind recommendations and think through the next steps. Trainees highlighted brief clinical pearls as superior to longer teaching sessions. The "vibe" between resident and fellow was described as a prerequisite to meaningful teaching and included aspects of interest, receptivity, tone, and attitude. Face-to-face interactions were preferred by many trainees, from initial consults to seeing patients or co-rounding. Timing and workload reflected discordant schedules, including time of day and week, but setting a planned time for teaching was beneficial.

CONCLUSION

Relevant, bite-sized educational content combined with a good vibe and optimal timing creates a context in which consult fellows can foster meaningful teaching opportunities for residents.

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

IMPORTANCE

Subspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices.

OBJECTIVES

To identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023.

EXPOSURES

Patient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics.

MAIN OUTCOMES AND MEASURES

The primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians.

RESULTS

We evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.

Bridge Builders: A Qualitative Study of Fellows' Successful Supervision of Residents

PURPOSE

Clinical fellows, those training to become subspecialists in a program certified by the Accreditation Council for Graduate Medical Education, supervise residents on inpatient subspecialty rotations. Unlike for supervising residents or for faculty, there is a paucity of literature describing fellows' supervision of residents. The aim of this study was to understand residents' and fellows' perception of successful supervision of residents by fellows on inpatient subspecialty rotations to inform the development of curricula to support fellows as supervisors.

METHOD

Using grounded theory methodology, the authors held focus groups in May 2020 of pediatric residents and pediatric subspecialty fellows at Boston Children's Hospital, Boston, Massachusetts. Focus groups were conducted until thematic saturation was achieved. Deidentified transcripts were independently coded by 2 authors. The author team consolidated the codes into themes and developed an interpretive model for fellows' successful supervision of residents. Key results were confirmed via member checking.

RESULTS

The authors conducted 4 resident focus groups, composed of 16 pediatric residents, and 4 fellow focus groups, composed of 13 pediatric subspecialty fellows. Participants perceived that fellows who provided successful resident supervision advanced residents' professional growth and supported residents' development along 5 "bridges": (1) generalist to subspecialist, (2) trainee to autonomous practitioner, (3) individual to member of the interprofessional team, (4) emerging physician to patient-facing care provider, and (5) newcomer to engaged clinical learner. Fellows can further residents' growth in these areas by demonstrating approachability, empathy, appreciation, and kindness.

CONCLUSIONS

As newcomers on inpatient subspecialty rotations, residents engage in legitimate peripheral participation. Fellows who are successful supervisors move residents toward full participation in their profession via the bridge model. The fellow-resident dynamic carries advantages of near-peer learning. Fellows can harness their role, subspecialty knowledge, and familiarity with the training environment to enhance resident supervision.

The Cognitive Load of Inpatient Consults: Development of the Consult Cognitive Load Instrument and Initial Validity Evidence

PURPOSE

Fellows and residents provide inpatient consultations. Though consults vary considerably, measuring the associated cognitive load (CL) is key to guiding faculty on how to optimize learning during consults. However, existing CL instruments, such as the unidimensional Paas scale, cannot separate the 3 components of CL and may miss the nuances of consult CL. Therefore, the authors developed the Consult Cognitive Load (CCL) instrument to measure the 3 CL components during consults.

METHOD

In 2018-2019, the authors developed the CCL at the University of California, San Francisco, using Wilson's constructive approach to measurement. To generate content and response process validity evidence, the authors consulted the literature and experts to generate construct maps, items, and a scoring rubric and conducted cognitive interviews. They administered the CCL to internal medicine and psychiatry trainees across 5 University of California campuses and used Rasch family and linear regression models to assess internal structure validity and relationships to key predictor variables. They compared the CCL with the Paas scale using Wright maps and used latent correlations to support separating CL into 3 components.

RESULTS

Analysis revealed appropriate fit statistics, appropriate mean respondent location increases across all levels, threshold banding, and expected relationships with key predictor variables. The CCL provided more coverage of the 3 CL components compared with the Paas scale. Correlations among the 3 CL components were not strong, suggesting that the CCL offers more nuance than a unidimensional measure of CL in the context of consults.

CONCLUSIONS

This study generated initial validity evidence to support the CCL's use as a measure of consult CL and supports measuring the 3 CL components separately rather than as a single construct in the context of consults. Learners and faculty could compare learner CCL scores with reference scores to promote reflection, metacognition, and coaching.

Improving Inpatient Consult Communication Through a Standardized Tool

OBJECTIVES

To increase the number of essential consult elements (ECEs) included in initial inpatient consultation requests between pediatric residents and fellows through implementation of a novel consult communication tool.

METHODS

Literature review and previous needs assessment of pediatric residents and fellows were used to identify 4 specific ECEs. From February to June 2018, fellows audited verbal consult requests at a medium-sized, quaternary care children's hospital to determine the baseline percentage of ECE components within consults. A novel consult communication tool containing all ECEs was then developed by using a modified situation-background-assessment-recommendation (SBAR) format. The SBAR tool was implemented over 3 plan-do-study-act cycles. Adherence to SBAR, inclusion of ECEs, and consult question clarity were tracked via audits of consult requests. A pre- and postintervention survey of residents and fellows was used to examine perceived miscommunication and patient care errors and overall satisfaction.

RESULTS

The median percentage of consults containing ≥3 ECEs increased from 50% preintervention to 100% postintervention with consult question clarity increasing from 52% to 92% (P < .001). Overall perception of consult miscommunication frequency decreased (52% vs 18%; P < .01), although there was no significant change in resident- or fellow-reported patient errors. SBAR maintained residents' already high consult satisfaction (96% vs 92%; P = .39) and increased fellows' consult satisfaction (51% vs 91%; P < .001).

CONCLUSIONS

Implementation of a standardized consult communication tool resulted in increased inclusion of ECEs. Use of the tool led to greater consult question clarity, decreased perceived miscommunication, and improved overall consult satisfaction.

Inpatient Dermatology Best Practice Strategies for Educating and Relaying Findings to Colleagues

Purpose of Review

This review examines the role of education and relaying findings to non-dermatologist colleagues when performing inpatient dermatology consults. We highlight best practices for communication and education.

Recent Findings

Non-dermatologists receive minimal training on the diagnosis and the management of skin conditions. Efforts to teach dermatology in the inpatient setting via traditional didactics have been met with limited success, and hospitalists have indicated a desire to learn from specialists. Incorporating education into standard consultation practices including the note, one-on-one communication, and bedside rounds can efficiently improve teaching and patient care.

Summary

Our key principles of consultation emphasize communication, use of pre-existing components of a consultation to teach, and close follow-up. Inpatient dermatologists can implement these simple but effective measures to encourage education and communication with primary teams for both in-person and telehealth consults.