Teaching during consultation: factors affecting the resident-fellow teaching interaction

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.

Skills, Not Just Knowledge: Infectious Diseases Fellows' Recommendations Regarding Antimicrobial Stewardship Training

BACKGROUND

Antimicrobial stewardship (AS) is an important topic in infectious diseases (ID) training, yet many ID fellowships lack formal training, and little is known about fellows' learning preferences.

METHODS

We conducted 24 in-depth interviews with ID fellows across the United States during 2018 and 2019 to explore their experiences with and preferences for AS education during fellowship. Interviews were transcribed, deidentified, and analyzed to identify themes.

RESULTS

Fellows had variable exposure to AS before and during fellowship, which impacted their knowledge about and attitude toward stewardship as a career; however, all fellows expressed the importance of learning general stewardship principles during fellowship. Some fellows' training included mandatory stewardship lectures and/or rotations, but most fellows felt their primary stewardship learning occurred through informal experiences in the clinical setting, such as holding the antimicrobial approval pager. Fellows expressed a preference for a standardized, structured curriculum that included in-person practical, interactive discussions with multidisciplinary faculty along with the opportunity to practice and apply their skills; however, they emphasized that time needed to be set aside for those educational activities. Although they wanted to learn the evidence and rationale for stewardship recommendations, they especially wanted training in and feedback on how to communicate stewardship recommendations to other health professionals, particularly in the setting of conflict.

CONCLUSIONS

ID fellows believe that standardized AS curricula should be included in their fellowship training, and they prefer structured, practical, and interactive learning experiences.

Clinician Educator Pathway for Nephrology Fellows: The University of North Carolina Experience

Nephrologists have a significant role in educating and mentoring trainees. They are considered role models and a major reason for fellows to be attracted to the specialty. Nephrology training programs not only support fellows in their teaching endeavors but also provide them with the necessary knowledge and skills required for advancing their careers as clinician educators. However, such career development tracks are limited in number and most focus on early career faculty. Here we present an overview of the various teaching opportunities for fellows at the University of North Carolina (UNC) Nephrology fellowship program and the development of a fellow-oriented clinician educator track. Our goal as part of the nephrology community is to empower the current nephrology fellows to develop fulfilling careers as nephrology clinician educators.

Patient and Clinician Perceptions of Factors Relevant to Ideal Specialty Consultations

IMPORTANCE

Inpatient subspecialty consultations, a common and expensive practice within inpatient medicine, do not always go well; however, little is known about the failure modes of consultation, thus making it difficult to identify interventions to improve consultation quality.

OBJECTIVE

To understand how stakeholders envision the ideal inpatient consultation and identify how and why consultations commonly fall short of this ideal.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used in-depth, semistructured interviews collected from April to October 2017 and analyzed from January 2018 to February 2020 using conventional content analysis. The setting was a single academic medical center in Boston, Massachusetts. Participants were hospitalists and specialists who had requested or performed a consultation for a non-intensive care unit patient in the previous 4 months, patients who had received a consultation while hospitalized at the medical center in the previous 15 months, and family members of such patients.

MAIN OUTCOMES AND MEASURES

Consultation experiences reported by participants. Clinicians were asked about characteristics of the ideal consultation, positive and negative consultation experiences, costs and benefits, and suggested improvements. Patients and family members were asked about their consultation experience, changes in care, communication preferences, and suggested improvements.

RESULTS

The study included 38 participants: 17 specialists, 13 hospitalists, 4 patients, and 4 family members. More than half (21 of 38) of the participants were female. There were 11 key information exchanges identified that occur among the specialist team, primary team, and patient/family during an ideal consultation. These exchanges are time sensitive and primarily carried out through unwritten protocols. We also identified 6 defects (process failures) that commonly derail information exchanges (complete omission, exclusion of a key stakeholder, poor timing, incomplete or inaccurate information, and misinterpretation) and 5 contextual factors (roles and boundaries, professionalism, team hierarchy, availability, and operational know-how) that influence how information exchange unfolds, making some consultations more prone to defects.

CONCLUSIONS AND RELEVANCE

Successful inpatient consultation requires a complicated, sequenced series of time-sensitive information exchanges that are highly vulnerable to failure. Maximizing the benefit of consultations will likely entail not only minimizing low-value consultations but also actively preventing defects, such as information inaccuracies and misinterpretation, that commonly derail the consultation process.

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.

Essential consultants' skills and attitudes (Willing CONSULT): a cross-sectional survey

BACKGROUND

Despite multi-professional collaboration via consultation being increasingly important given the variety of disease diagnoses and treatment, the key elements as consultants remain unclear. The study aimed to identify the skills and attitudes that are important for consultants from the residents' perspective so that they can be targeted as priority goals in subsequent educational interventions.

METHODS

We conducted our research in two phases: a preliminary survey (May 1 to 14, 2020) and a main survey (June 1 to 14, 2020). As a preliminary survey, first-year postgraduate residents at St. Luke's International Hospital in Tokyo, Japan, were first asked an open-ended question about the types of skills and attitudes that are important for consultants. After eliminating duplicate answers, there were 19 skills and attitudes in total. In the main survey with residents who completed their residency training at our institute, from 2014 to 2018 and current residents (2019-2020), we first asked them about their demographic characteristics (gender, years of postgraduate education, and type of specialty). Then, they answered how important each skill and attitude are for consultants. All 19 items were scored on a seven-point Likert scale that ranged from 0 (completely disagree) to 6 (totally agree). Cronbach's alpha confirmed the internal consistency of the questionnaire items. Principal component analysis and exploratory factor analysis were performed.

RESULTS

The survey included 107 individuals (61.1 %, 175 potential participants). The median postgraduate years of education was four (interquartile range: 2-5), and 64.5 % were men (n = 69). Seven key elements for consultants were identified and termed Willing CONSULT. These included (1) willingness (willingness to accept consultation requests), (2) contact (easy access to consultants), (3) needs (consideration of consulters' needs), (4) suggestions and support (providing clear recommendations and suggestions, following up on the patients, and supporting the consulters continuously), (5) urgency (considering the situation's urgency and responding appropriately), (6) learning opportunities (providing teaching points), and (7) text (writing medical records).

CONCLUSIONS

We propose Willing CONSULT, which are important skills and attitudes for consultants.

Patient-centered oncosurgical planning with cancer models in subspecialty education

BACKGROUND

A fundamental aspect of oncosurgical planning in organ resections is the identification of feeder vessel details to preserve healthy organ tissue while fully resecting the tumors. The purpose of this study was to determine whether three-dimensional (3D) cancer case models of computed tomography (CT) images will assist resident-level trainees in making appropriate operative plans for organ resection surgery.

METHODS

This study was based on the perception of surgery residents who were presented with 5 different oncosurgical scenarios. A five-station carousel including cases of liver mass, stomach mass, annular pancreas, pelvic mass and mediastinal mass was formed for the study. The residents were required to compare their perception level of the cases with their CT images, and 3D models in terms of identifying the invasion of the mass, making differential diagnosis and preoperative planning stage.

RESULTS

All residents have given higher scores for models. 3D models provided better understanding of oncopathological anatomy and improved surgical planning. In all scenarios, 70-80% of the residents preferred the model for preoperative planning. For surgical choice, compared to the CT, the model provided a statistically significant difference in terms of visual assessment, such as tumor location, distal or proximal organotomy (p:0.009). In the evaluation of presacral mass, the perception of model was significantly better than the CT in terms of bone-foramen relationship of chondrosarcoma, its origin, geometric shape, localization, invasion, and surgical preference (p:0.004). The model statistically significantly provided help to evaluate and prepare the case together with the colleagues performing surgery (p:0.007). Commenting on the open-ended question, they stated that the tumor-vessel relationship was clearly demonstrated in the 3D model, which has been very useful.

CONCLUSIONS

With the help of 3D printing technology in this study, it is possible to implement and evaluate a well-structured real patient scenario setup in cancer surgery training. It can be used to improve the understanding of pathoanatomical changes of multidisciplinary oncologic cases. Namely, it is used in guiding the surgical strategy and determining whether patient-specific 3D models change pre-operative planning decisions made by surgeons in complex cancer mass surgical procedures.

Enhancing the Inpatient Consultation Learning Environment to Optimize Teaching and Learning

Subspecialty consultation is an increasingly used resource in inpatient medicine. Teaching the primary team is an important element of effective consultation and has many potential benefits. However, within academic medical centers many barriers to effective consultation and the consult learning environment exist. High workload, burnout, inexperience, lack of familiarity between teams, quality of the consult requests, and pushback may impede teaching and learning. Herein, the authors review the role of teaching and learning during consultation, challenges to effective consultation facing fellows, and interventions that can enhance primary team-fellow interactions and learning.

The change laboratory in medical education: Two examples of tackling contradictory challenges

CONTEXT

Medical education and workplace learning is bound to develop through tensions between providing high quality patient care and providing training of the future specialist healthcare workforce. This paper on the Change Laboratory and the theoretical framework supporting it, shows examples on how to explore inherent and contradictory tensions in medical education and healthcare and use them as a driving force for change. We argue that the traditional tools and theories for change and fixing tensions are inadequate and therefore suggest an alternative strategy found in Cultural-Historical Activity Theory (CHAT) and the Change Laboratory method.

METHODS

The Change Laboratory intervention method builds on the theoretical framework of CHAT and specifically the theory of expansive learning. The Change Laboratory intervention method uses well-defined steps for participants in collaboration with researchers/facilitators to co-construct and develop new ways of going about their work practice.

RESULTS

Drawing on our own research on implementing the Change Laboratory intervention method we present two case examples of interventions in respectively a Finnish surgical unit and a Danish paediatric outpatient clinic.

CONCLUSIONS

The Change Laboratory intervention offers ways to systematically leverage tensions in medical education and thus could be effective in developing and designing organisational and professional change. It is not a quick fix solution as participators must be motivated and engaged in uncovering inherent contradictions in their activity systems (workplace) and get familiar with the concepts and theory underlying the intervention and its procedures. Profound knowledge and transformative agency emerges when participants and facilitators/researchers are given the time and opportunity to analyse both historical practice, current data on practice, and organisational issues collaboratively in order to envision and redesign their practice and learning environment.

Education of Infectious Diseases Fellows During the COVID-19 Pandemic Crisis: Challenges and Opportunities

One of the many challenges that has befallen the Infectious Diseases and Graduate Medical Education communities during the coronavirus disease 2019 (COVID-19) pandemic is the maintenance of continued effective education and training of the future leaders of our field. With the remarkable speed and innovation that has characterized the responses to this pandemic, educators everywhere have adapted existing robust and safe learning environments to meet the needs of our learners. This paper will review distinct aspects of education and training of the Infectious Diseases fellows we believe the COVID-19 pandemic has impacted most, including mentoring, didactics, and wellness. We anticipate that several strategies developed in this context and described herein will help to inform training and best practices during the pandemic and beyond.

Real-time Assessment of Neurology Residents' Perceptions of Inappropriate Consults

BACKGROUND

We sought to characterize perceptions of inappropriate neurology consults of neurology residents (NR) and requesting providers (RP) immediately following the consult interaction.

METHODS

Student investigators were embedded in the Mount Sinai neurology consult service for 4 weeks in May/June 2018. For each consecutive neurology consult the NR's real-time attitudes toward the consult were evaluated with a survey using Likert scales. A similar survey was immediately administered to the RP who called the consult. Response scores for each attribute were dichotomized and data were analyzed descriptively in SPSS.

RESULTS

Data from 69 consults were collected. NRs perceived 45% of consults as inappropriate and 82% of all consults as low urgency. When NRs perceived a consult as inappropriate, they felt more resistance (r=-0.79). NRs also felt more resistant when they thought that the RP could have cared for the patient without the consult (r=0.79). NRs felt that perceived medicolegal risk highly influenced the RP's decision to call a consult in 36% of cases. Of these "high liability" consults, NRs considered 76% inappropriate and 100% low urgency.

CONCLUSIONS

NRs were more likely to rate consults as inappropriate if they were also perceived as low urgency, strongly influenced by liability concerns, or unnecessary due to belief that the RP could have cared for the patient without the consult. Our findings suggest a discrepancy in how NRs and RPs perceive neurology consult appropriateness, and help to elucidate potential drivers of these perceptions that could be barriers to education and to interdisciplinary care.

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.

Impact of Fellows-as-Teachers Workshops on Teaching Rounds: An Observational Study in an ICU

Supplemental Digital Content is available in the text.

During training, fellows serve as teachers and role models for junior colleagues. Fellows-as-teachers curricula may support these roles, but little is known about their effectiveness and durability. We sought to measure the long-term effects on ICU rounds after administering fellows-as-teachers workshops.

Addressing the rheumatology workforce shortage: A multifaceted approach

A significant challenge facing the field of rheumatology is the projected gap between the growing demand for rheumatologists and the available workforce. In order to improve access to care, augmenting the rheumatology workforce is required. Herein we discuss potential solutions to the anticipated workforce shortage, including 1) expanding the training of rheumatology physicians; 2) increasing nurse practitioner, physician assistant and pharmacist utilization in rheumatology practice; 3) growing the use of telemedicine; and 4) reducing burnout in order to retain practicing rheumatologists. Building on the existing literature in these areas, we propose a multifaceted approach to addressing the rheumatology workforce shortage.

Surgical planning with patient-specific three-dimensional printed pancreaticobiliary disease models - Cross-sectional study

BACKGROUND

Three-dimensional (3D) printing has been increasingly used in medical applications with the creation of accurate patient-specific 3D printed models in medical imaging data. This study has been planned based on the fact that research on 3D printing in pancreaticobiliary disease is limited due to lack of studies on validation of model accuracy.

METHODS

This is an innovative study where general surgery residents are presented 5 distinct hepatopancreatobiliary disease scenarios to generate a perception and required to compare their perception level of these cases with magnetic resonance cholangiopancreatography (MRCP), 3D images and 1:1 solid models that the pathology, diverse diagnosis and presurgery diagnosis stages can be observed. This study is single-centered.

RESULTS

The dilated pancreaticobiliary intervention based on scenarios for general surgery residency was more original since there was no prior study that includes both model building and the evaluation of the perception created by the model. Five scenarios provided qualitative assessment with results showing the usefulness of 3D models when used as clinical tools in preoperative planning, simulation of interventional procedures, surgical education, and training. The perception level in the 3D model, MRCP (Z: 3.854, p: 0.000) and the 3D image (Z: 2.865, p: 0.004) was higher; likewise, the 3D-STL image was higher compared to the MRCP image (Z: 3.779, p: 0.000). All subspecialists agree that 3D models provided better understanding of dilated pancreaticobiliary pathoanatomy and improved surgical planning.

CONCLUSIONS

A thoroughly outlined genuine patient situation layout aimed for general surgery training can be installed and monitored with the support of 3D printing technology of this study. This can be utilized to develop the comprehension of pathoanatomical variations of complex pancreaticobiliary illness and to adopt a surgical approach.

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

PURPOSE

To characterize the methods of inpatient consult communication, given new communication modalities; to explore residents' and fellows' perspectives on the ideal consult and how this consult could affect their teaching, learning, and patient safety; and to identify barriers to and strategies for optimizing consultations.

METHOD

Using qualitative grounded theory, the authors conducted semistructured focus groups with pediatric residents and fellows at Lucile Packard Children's Hospital at Stanford University from October 2016 to September 2017, using questions developed by expert consensus to address study objectives. Sessions were audiorecorded and transcribed verbatim. Two authors independently coded the transcripts and reconciled codes to develop categories and themes using constant comparison. The third author validated the codes, categories, and themes. To ensure trustworthiness, participants edited the themes for accuracy.

RESULTS

Twenty-seven residents and 16 fellows participated in 7 focus groups (3 with residents, 4 with fellows). Four themes emerged: (1) Many forms of communication are successfully used for initial inpatient consult recommendations (in person, phone, text messages, notes in electronic medical records); (2) residents and fellows prefer in-person communication for consults, believing it leads to improved teaching, learning, and patient safety; (3) multiple strategies can optimize consults regardless of communication modality; and (4) how residents frame the initial consult affects the interaction and can increase fellow engagement, which leads to more fellow teaching, residents' improved understanding, and better patient care.

CONCLUSIONS

Residents and fellows believe that structured initial consults conducted in person improve teaching, learning, and patient care. Several strategies exist to optimize this process.

What Are We Really Talking About? An Organizing Framework for Types of Consultation and Their Implications for Physician Communication

Consultation amongst providers is a foundation of modern health care and one of the most frequent means of interdisciplinary communication. Accordingly, clear and efficient communication between providers and across medical specialties during consultation is essential to patient care and a collegial work environment. Traditionally, consultation requests are felt to require a clear question that falls within the purview of the consultant's expertise. However, this narrow constraint is often lacking in the real-world clinical environment and may in fact be detrimental to physician communication and patient care. In this Perspective, the authors propose an organizing framework of seven specific consultation types, which apply broadly across disciplines: ideal, obligatory, procedural, S.O.S., confirmatory, inappropriate, and curbside. The authors describe what factors define each type and the benefits and pitfalls of each. The proposed framework may help providers have more productive, efficient, and collegial conversations about patient care, which may facilitate improved work satisfaction and an enhanced learning environment.

A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage

GOAL

Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers' perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage.

MATERIALS AND METHODS

We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method.

FINDINGS

The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers' questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions.

CONCLUSIONS

The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians' voices.

Conquering Consultations: A Guide to Advances in the Science of Referral-Consultation Interactions for Residency Education

Consultations with specialist services occur with regularity in the emergency department (ED). Emergency physician interactions with consultants in the ED offer an amazing opportunity for collegial patient care but can also present a number of challenges. Navigating the consultation process requires effective communication skills that are considered a core competency within the Accreditation Council for Graduate Medical Education, as well as the CanMEDS frameworks of the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. Because of time pressure, environmental complexities, patient acuity, and the fast pace of the ED, learning this skill can be challenging for trainees and is something many attending physicians will struggle with at times. It has been established that trustworthiness and familiarity are 2 key components within the referral-consultation process. Both components rely on reputation, which creates a challenge in a training environment in which one's knowledge base and clinical acumen is a constant work in progress. Moreover, poor communication contributes to problematic patient care and decreased patient satisfaction. Knowing this, we believe it is imperative that residents be formally trained in this important skill. In this article, we introduce and highlight the most recent advances in standardized approaches to the referral-consultation process, including the 5C (contact, communicate, core question, collaborate, close the loop), PIQUED (prepare, identify, question, urgency, educational modifications, debrief), and CONSULT (contact courteously, orient, narrow question, story, urgency, later, thank you) models. Common roadblocks and complicating factors involved in resident-consultant interaction are also reviewed, ending with best-practice recommendations for consultants involved in resident education, as well as free open access medical education resources.

Developing internal medicine subspecialty fellows' teaching skills: a needs assessment

BACKGROUND

For academic physicians, teaching represents an essential skill. The proliferation of educator training programs aimed at residents and medical students signals the increasing commitment of training programs to develop teaching skills in their trainees as early as possible. However, clinical fellowships represent an important opportunity to advance training as educators. In addition to enriching the pipeline of future teachers, developing fellows as teachers augments the training experience for more junior trainees and may impact patient care. Fellows' needs for programs to improve teaching skills have been largely unexplored.

METHODS

We conducted a multi-institutional needs assessment of internal medicine (IM) subspecialty fellows to gauge interest in teaching and improvement of teaching skills. We surveyed IM subspecialty fellows at three academic medical centers about their access to fellow-as-teacher programs and other mechanisms to improve their teaching skills during fellowship. We also elicited their attitudes towards teaching and interest in training related to teaching skills.

RESULTS

One hundred eighty-three fellows representing 20 programs and nine different subspecialties responded to the survey (48% response rate). The majority of participants (67%) reported having no specific training focused on teaching skills and only 12% reported receiving regular feedback about their teaching during their fellowship. Seventy-nine percent of fellows anticipated teaching to be part of their careers, and 22% planned to participate in medical education scholarship. Fellows reported a strong interest in teaching and programs aimed at improving their teaching skills.

CONCLUSIONS

The majority of fellows reported a lack of mechanisms to advance their teaching skills as fellows, despite anticipating teaching to be an important aspect of their future careers and having strong interest in such programs. Our findings at three academic medical centers confirm a lost opportunity among subspecialty fellowships to accelerate teaching skills development for future educators.

Teaching & Learning Tips 10: Interspecialty teaching through inpatient dermatology consults

Medical students and residents often have little experience in placing or responding to dermatologic consults in the inpatient setting when they first begin training. Trainees often learn what and how to communicate through observation or trial and error. We propose that dermatologists can play an active role in facilitating interspecialty education and improving patient outcomes by teaching in a systematic fashion.

Learning how to learn using simulation: Unpacking disguised feedback using a qualitative analysis of doctors' telephone talk

INTRODUCTION

Telephone talk between clinicians represents a substantial workplace activity in postgraduate clinical education, yet junior doctors receive little training in goal-directed, professional telephone communication.

AIM

To assess educational needs for telephone talk and develop a simulation-based educational intervention.

METHODS

Thematic analysis of 17 semi-structured interviews with doctors-in-training from various training levels and specialties.

RESULTS

We identified essential elements to incorporate into simulation-based telephone talk, including common challenging situations for junior doctors as well as explicit and informal aspects that promote learning. These elements have implications for both junior doctors and clinical supervisors, including: (a) explicit teaching and feedback practices and (b) informal conversational interruptions and questions. The latter serve as "disguised" feedback, which aligns with recent conceptualizations of feedback as "performance relevant information".

CONCLUSIONS

In addition to preparing clinical supervisors to support learning through telephone talk, we propose several potential educational strategies: (a) embedding telephone communication skills throughout simulation activities and (b) developing stand-alone curricular elements to sensitize junior doctors to "disguised" feedback during telephone talk as a mechanism to augment future workplace learning, i.e. 'learning how to learn' through simulation.

Fellow as Clinical Teacher (FACT) Curriculum: Improving Fellows' Teaching Skills During Inpatient Consultation

INTRODUCTION

Multiple barriers, including time constraints, a demanding teaching environment, and lack of longitudinal relationships with residents, make it challenging for fellows and learners to engage in effective teaching during consultation.

METHODS

The Fellow as Clinical Teacher (FACT) curriculum was developed to overcome such barriers and improve fellow teaching in the setting of inpatient consultation. The FACT curriculum consists of two 45- to 60-minute small-group sessions designed for subspecialty fellows. The first session focuses on overcoming barriers to teaching and application of the principles of adult learning theory. The second introduces the PARTNER (partner with resident, assess the learner, reinforce positives, teaching objectives, new knowledge, execute recommendations, review) framework for teaching during consultation and uses video examples to model the application of this framework, allowing fellows to practice its implementation through role-play.

RESULTS

Previously, the FACT curriculum was shown to improve teaching skills of rheumatology and pulmonary/critical care fellows as evaluated by objective structured teaching exercises. Here, the curriculum has been expanded to 51 internal medicine and pediatrics fellows in 15 different training programs. The curriculum improved fellow teaching skills as assessed by self-assessment surveys. It was highly rated by participants, and fellows reported being more likely to teach during consultation following this educational intervention.

DISCUSSION

The FACT curriculum can be integrated into subspecialty training programs to improve the teaching skills of internal medicine and pediatrics fellows in the setting of inpatient consultation. Ultimately, improved teaching from fellows may have broad-reaching effects for residents, patients, and the fellows themselves.

It's all about relationships : A qualitative study of family physicians' teaching experiences in rural longitudinal clerkships

INTRODUCTION

The relationship between preceptor and trainee is becoming recognized as a critical component of teaching, in particular in the negotiation of feedback and in the formation of professional identity. This paper elaborates on the nature of the relationships between preceptor and student that evolve in the context of rural longitudinal integrated clerkships (LICs).

METHODS

We drew on constructivist grounded theory for the research approach. We interviewed nine LIC family practice preceptors from three sites at one educational institution. We adapted the interview framework based on early findings. We analyzed the data through a constant comparative process. We then drew on concepts of relationship-based learning as sensitizing concepts in a secondary analysis.

RESULTS

We constructed three themes from the data. First, preceptors developed trusting professional and personal relationships with students over time. These relationships expanded to include friendship, advocacy, and ongoing contact beyond the clerkship year. Second, preceptors' approach to teaching was anchored in the relationship with an understanding of the individual student. Third, preceptors set learning goals collaboratively with their students, based not only on program objectives, but also with the student as a future physician in mind.

DISCUSSION

Our findings suggest that rural family medicine preceptors developed engaged and trusting relationships with their students over time. These relationships imbued all activities of teaching and learning with an individual and personal focus. This orientation may be a key factor in supporting the learning outcomes demonstrated for students studying in rural LICs.

Development and Evaluation of a Novel Survey Tool Assessing Inpatient Consult Service Performance

BACKGROUND

Subspecialty consultation in inpatient medicine is increasing, and enhancing performance of consultation services may have a broad-reaching impact. Multisource feedback is an important tool in assessing competence and improving performance. A mechanism for primary team resident feedback on performance of consult services has not been described.

OBJECTIVE

We developed and evaluated an instrument designed to assess internal medicine (IM) subspecialty inpatient consult service performance. We hypothesized that the instrument would be feasible to administer and provide important information to fellowship directors.

METHODS

The instrument was administered in 2015 and 2016 at a single academic center. All IM residents were invited to evaluate 10 IM subspecialty consult services on 4 items and an overall satisfaction rating. The instrument allowed for free-text feedback to fellows. Program directors completed another survey assessing the impact of the consult service evaluation.

RESULTS

A total of 113 residents responded (47 in 2015 and 66 in 2016, for a combined response rate of 35%). Each of the 4 items measured (communication, professionalism, teaching, and pushback) correlated significantly with the overall satisfaction rating in univariate and multivariate analyses. There were no differences in ratings across postgraduate year or year of administration. There was considerable variation in ratings among the services evaluated. The 7 program directors who provided feedback found the survey useful and made programmatic changes following evaluation implementation.

CONCLUSIONS

A primary team resident evaluation of inpatient medicine subspecialty consult services is feasible, provides valuable information, and is associated with changes in consult service structure and curricula.

Fellow As Teacher Curriculum: Improving Rheumatology Fellows' Teaching Skills During Inpatient Consultation

OBJECTIVE

Enhancing rheumatology fellows' teaching skills in the setting of inpatient consultation may have a broad positive impact. Such efforts may improve fellows' clinical skills and overall patient care. Most importantly, effective resident-fellow teaching interactions may not only increase residents' knowledge of rheumatology but may influence their career choice. However, a number of barriers to the resident-fellow teaching interaction have been identified, including fellows' teaching skills. We developed the Fellow As Clinical Teacher (FACT) curriculum in order to enhance fellows' teaching skills during inpatient consultation.

METHODS

The FACT curriculum was delivered in two 45-minute workshops during the 3-day Winter Symposium of the Carolinas Fellows Collaborative. We evaluated its effect with self-assessment surveys and fellow performance on the objective structured teaching exercise (OSTE) before and after participation in the curriculum.

RESULTS

Nineteen fellows from 4 rheumatology training programs participated in the pre- and post-curriculum OSTEs and 18 fellows completed pre- and post-curriculum surveys. OSTE scores improved on 5 of the 8 items assessed, and the total OSTE score improved as well (34.7 versus 29.5; P < 0.01) after the FACT curriculum. Fellows' self-assessment of their teaching skills and intent to teach during consultation also increased after participation in the curriculum.

CONCLUSION

The FACT curriculum, focused on teaching during consultation, improved fellows' teaching skills and attitudes toward teaching. Improving and increasing fellow teaching, particularly in the consultation setting, may impact patient care, resident and fellow learning, and teaching skills of future faculty, and could potentially influence residents' career choice.

Use of Fellow as Clinical Teacher (FACT) Curriculum for Teaching During Consultation: Effect on Subspecialty Fellow Teaching Skills

BACKGROUND

Subspecialty consultation in inpatient care is increasing. Teaching by subspecialty fellows in a consultation setting may be an important source of work-based learning for students and residents. However, teaching and evaluation of learners in this context may be challenging due to personal and systems-based barriers.

OBJECTIVE

We developed and evaluated a framework designed to overcome barriers to teaching and to improve fellow teaching skills during inpatient consultation.

METHODS

The PARTNER (Partner with resident, Assess the learner, Reinforce positives, Teaching objectives, New knowledge, Execute recommendations, Review) framework was delivered to rheumatology and pulmonary and critical care medicine fellows at 3 academic medical centers as part of a 2-session Fellow as Clinical Teacher (FACT) curriculum. Fellows' teaching skills were evaluated using an objective structured teaching exercise (OSTE) pre- and postcurriculum, and at the end of the academic year. Self-assessment surveys were used to evaluate fellows' self-perception of teaching skills.

RESULTS

Twelve of 16 eligible fellows (75%) participated in the program and completed 73 OSTE cases. Teaching skills measured by OSTEs and self-assessment surveys improved after administration of the FACT curriculum. There was no significant skill decay at the end-of-year evaluation. The curriculum was rated highly, and 73% (8 of 11) of fellows stated they would teach more frequently as a result of the intervention.

CONCLUSIONS

The FACT curriculum was practical and feasible, and significantly improved fellows' teaching skills teaching during inpatient consultation.

Fellows as Teachers: Raising the Educational Bar

Fellows are expected to educate trainees, peers, and patients, during and long after fellowship. However, there has been relatively little emphasis on the acquisition of teaching skills in fellowship programs. Challenges to teaching by fellows during subspecialty training include demanding clinical duties, their limited knowledge base in the field, brief contact time with learners during consultative roles, and, for new fellows, personal unfamiliarity with the learners and hospital culture. Fellows' teaching skills can be improved by formal curricula addressing teaching, and by direct observation and feedback of teaching akin to what is provided for learning clinical care. Further expansion of fellow-as-teacher programs will allow in-depth training for fellows seeking careers as medical educators. Even without such dedicated programs, emphasis on honing teaching skills during fellowship will telegraph the importance of teaching and help evolve divisional culture. Such efforts can have a positive impact on patients and learners, and enhance the teaching skills of future faculty.

[Consultation skills training as an element of general practice training in Germany - a qualitative survey]

INTRODUCTION

The consultation is at the heart of general practice. It is the central setting through which primary care is delivered. The competency requirements are laid down internationally by competency-based curricula for undergraduate and postgraduate education. So far, there is no competency-based vocational training to develop consultation skills in general practice in Germany. The study describes experiences with consultation skills training as an element of general practice training as reported by trainees and trainers in Germany.

METHODS

A qualitative and exploring approach was chosen because there is little experience with the German situation. We conducted structured focus group interviews with trainees and trainers, respectively. We recruited all participants by e-mail via the mail distributor "Junge Allgemeinmedizin Deutschland" (JADE, a trainee and junior GP organization) and the academic teachers of the Friedrich-Alexander University Erlangen-Nürnberg. Altogether, four focus group interviews with three to five participants were conducted, varying in length from 25 to 65minutes. All interviews were recorded digitally and transcribed verbatim. Then a qualitative content analysis was performed.

RESULTS

The statements of the ten trainees and five trainers mapped a system of four main categories: (a) association with the term consultation, (b) parts of a consultation, (c) competencies required for professional practice, (d) consultation skills training as an element of vocational training. Overall, all participants regarded the consultation as the most important element in general practice. Important content of consultations is to build a relationship with the patient, gather information, conduct physical examinations and achieve informed consent on further proceedings. All participants agreed that physicians need different sets of competencies: medical expertise, communication skills, examination skills and professionalism. Finally, there was a broad consensus that a competency-based general practice training to support the development of consultation skills is lacking in Germany. The majority acknowledged the need for change.

CONCLUSION

So far, the consultation skills development within the general practice training in Germany is regarded as deficient. Both trainees and trainers have stressed the importance of change in vocational training. With the new competency-based curriculum for general practice in Germany and the associated development of supporting tools important prerequisites have been provided.

A randomized trial of an intervention to improve resident-fellow teaching interactions on the wards

BACKGROUND

Subspecialty fellows can serve as a tremendous educational resource to residents; however, there are multiple barriers to an effective resident-fellow teaching interaction in the setting of inpatient consultation. We designed and evaluated a resident-directed intervention to enhance communication and teaching during consultation on the general medicine wards.

METHODS

Five medical teams were randomized to receive the intervention over a 3 month period (3 control, 2 intervention teams). The intervention was evaluated with pre and post-intervention surveys.

RESULTS

Fifty-nine of 112 interns completed the pre-intervention survey, and 58 completed the post-intervention survey (53 % response rate). At baseline, 83 % of the interns noted that they had in-person interactions with fellows less than 50 % of the time. 81 % responded that they received teaching from fellows in less than 50 % of consultations. Following the intervention, the percentage of interns who had an in-person interaction with fellows greater than 50 % of the time increased in the intervention group (9 % control versus 30 % intervention, p = 0.05). Additionally, interns in the intervention group reported receiving teaching in more than 50 % of their interactions more frequently (19 % control versus 42 % intervention, p = 0.05). There were no differences in other measures of teaching and communication.

CONCLUSIONS

We demonstrate that a time-efficient intervention increased perceptions of in-person communication and the number of teaching interactions between interns and fellows. Further studies are warranted to determine whether such an approach can impact resident learning and improve patient care.

Introducing a Virtual Reality Experience in Anatomic Pathology Education

OBJECTIVES

A proper examination of surgical specimens is fundamental in anatomic pathology (AP) education. However, the resources available to residents may not always be suitable for efficient skill acquisition. We propose a method to enhance AP education by introducing high-definition videos featuring methods for appropriate specimen handling, viewable on two-dimensional (2D) and stereoscopic three-dimensional (3D) platforms.

METHODS

A stereo camera system recorded the gross processing of commonly encountered specimens. Three edited videos, with instructional audio voiceovers, were experienced by nine junior residents in a crossover study to assess the effects of the exposure (2D vs 3D movie views) on self-reported physiologic symptoms. A questionnaire was used to analyze viewer acceptance.

RESULTS

All surveyed residents found the videos beneficial in preparation to examine a new specimen type. Viewer data suggest an improvement in specimen handling confidence and knowledge and enthusiasm toward 3D technology. None of the participants encountered significant motion sickness.

CONCLUSIONS

Our novel method provides the foundation to create a robust teaching library. AP is inherently a visual discipline, and by building on the strengths of traditional teaching methods, our dynamic approach allows viewers to appreciate the procedural actions involved in specimen processing.

The paediatric change laboratory: optimising postgraduate learning in the outpatient clinic

BACKGROUND

This study aimed to analyse and redesign the outpatient clinic in a paediatric department. The study was a joint collaboration with the doctors of the department (paediatric residents and specialists) using the Change Laboratory intervention method as a means to model and implement change in the outpatient clinic. This study was motivated by a perceived failure to integrate the activities of the outpatient clinic, patient care and training of residents. The ultimate goal of the intervention was to create improved care for patients through resident learning and development.

METHODS

We combined the Change Laboratory intervention with an already established innovative process for residents, 3-h meetings. The Change Laboratory intervention method consists of a well-defined theory (Cultural-historical activity theory) and concrete actions where participants construct a new theoretical model of the activity, which in this case was paediatric doctors' workplace learning modelled in order to improve medical social practice. The notion of expansive learning was used during the intervention in conjunction with thematic analysis of data in order to fuel the process of analysis and intervention.

RESULTS

The activity system of the outpatient clinic can meaningfully be analysed in terms of the objects of patient care and training residents. The Change Laboratory sessions resulted in a joint action plan for the outpatient clinic structured around three themes: (1) Before: Preparation, expectations, and introduction; (2) During: Structural context and resources; (3) After: Follow-up and feedback. The participants found the Change Laboratory method to be a successful way of sharing reflections on how to optimise the organisation of work and training with patient care in mind.

CONCLUSIONS

The Change Laboratory approach outlined in this study succeeded to change practices and to help medical doctors redesigning their work. Participating doctors must be motivated to uncover inherent contradictions in their medical activity systems of which care and learning are both part. Facilitators must be willing to spend time analysing both historical paediatric practice, current data on practice, and steer clear of organisational issues that might hamper a transformative learning environment. To ensure long-term success, economical and organisational resources, participant buy-in and department leadership support play a major role.