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Schumacher DJ, Gielissen K, Kinnear B. Competency-based medical education: Connecting training outcomes to patient care. Curr Probl Pediatr Adolesc Health Care 2024; 54:101675. [PMID: 39142928 DOI: 10.1016/j.cppeds.2024.101675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
Competency-based medical education (CBME) is a patient-centered and learner-focused approach to education where curricula are delivered in a manner tailored to the individuals' learning needs, and assessment focuses on ensuring trainees achieve requisite and clearly specified learning outcomes. Despite calls to focus assessment on what matters for patients. In this article, the authors explore one aspect of this next era: the use of electronic health record clinical performance indicators, such as Resident-Sensitive Quality Measures (RSQMs) and TRainee Attributable and Automatable Care Evaluations in Real-time (TRACERs), for learner assessment. They elaborate on both the promise and the potential limitations of using such measures in a program of learner assessment.
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Affiliation(s)
- Daniel J Schumacher
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Katherine Gielissen
- Departments of Medicine and Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Benjamin Kinnear
- Departments of Pediatrics and Internal Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Barber C, van der Vleuten C, Chahine S. Validity evidence and psychometric evaluation of a socially accountable health index for health professions schools. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2024; 29:147-172. [PMID: 37347458 DOI: 10.1007/s10459-023-10248-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 05/28/2023] [Indexed: 06/23/2023]
Abstract
There is an expectation that health professions schools respond to priority societal health needs. This expectation is largely based on the underlying assumption that schools are aware of the priority needs in their communities. This paper demonstrates how open-access, pan-national health data can be used to create a reliable health index to assist schools in identifying societal needs and advance social accountability in health professions education. Using open-access data, a psychometric evaluation was conducted to examine the reliability and validity of the Canadian Health Indicators Framework (CHIF) conceptual model. A non-linear confirmatory factor analysis (CFA) on 67 health indicators, at the health-region level (n = 97) was used to assess the model fit of the hypothesized 10-factor model. Reliability analysis using McDonald's Omega were conducted, followed by Pearson's correlation coefficients. Findings from the non-linear CFA rejected the original conceptual model structure of the CHIF. Exploratory post hoc analyses were conducted using modification indices and parameter constraints to improve model fit. A final 5-factor multidimensional model demonstrated superior fit, reducing the number of indicators from 67 to 32. The 5-factors included: Health Conditions (8-indicators); Health Functions (6-indicators); Deaths (5-indicators); Non-Medical Health Determinants (7-indicators); and Community & Health System Characteristics (6-indicators). All factor loadings were statistically significant (p < 0.001) and demonstrated excellent internal consistency ( ω >0.95). Many schools struggle to identify and measure socially accountable outcomes. The process highlighted in this paper and the indices developed serve as starting points to allow schools to leverage open-access data as an initial step in identifying societal needs.
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Affiliation(s)
- Cassandra Barber
- School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Cees van der Vleuten
- School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Saad Chahine
- Faculty of Education, Queen's University, Kingston, ON, Canada
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Lyall MJ, Dear J, Simpson J, Lone N. Duration of consultant experience and patient outcome following acute medical unit admission: an observational cohort study. Clin Med (Lond) 2023; 23:458-466. [PMID: 37775159 PMCID: PMC10541280 DOI: 10.7861/clinmed.2022-0546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND The effect of the duration of consultant experience on clinical outcomes in the acute medical unit (AMU) model remains unknown. METHODS Unscheduled AMU admissions (n=66,929) admitted by 56 consultant physicians between 2017 and 2020 to two large teaching hospital AMUs in Lothian, Scotland were examined. The associations of consultant experience on AMU with patient discharge, mortality, readmission and postdischarge death were calculated adjusting for clinical acuity, pathology and comorbidity. RESULTS Increasing consultant experience was associated with a continuous increase in likelihood of early AMU discharge (odds ratio (OR) 1.08; 95% confidence interval (CI) 1.07-1.10; p<0.001 per 5 years' experience), which persisted after adjustment for confounders (OR 1.06; 95% CI: 1.01-1.11; p=0.01). There was no association with early readmission, death after discharge or 30-day inpatient mortality. The marginal effect estimate translates into 31 (95% CI: 25-36), 41 (95% CI: 30-53) and 52 (95% CI: 35-71) additional safe discharges per 1,000 admissions for clinicians of 15, 20 and 25 years' experience, respectively compared with those recently completing training. CONCLUSIONS Increasing consultant physician experience associates with early safe discharge after AMU admission. These data suggest that the support and retention of experienced clinicians is vital if escalating pressures on unscheduled medical care are to be addressed.
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Affiliation(s)
- Marcus J Lyall
- Usher Institute for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - James Dear
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Johanne Simpson
- Department of Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nazir Lone
- Usher Institute for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Smirnova A, Chahine S, Milani C, Schuh A, Sebok-Syer SS, Swartz JL, Wilhite JA, Kalet A, Durning SJ, Lombarts KM, van der Vleuten CP, Schumacher DJ. Using Resident-Sensitive Quality Measures Derived From Electronic Health Record Data to Assess Residents' Performance in Pediatric Emergency Medicine. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:367-375. [PMID: 36351056 PMCID: PMC9944759 DOI: 10.1097/acm.0000000000005084] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE Traditional quality metrics do not adequately represent the clinical work done by residents and, thus, cannot be used to link residency training to health care quality. This study aimed to determine whether electronic health record (EHR) data can be used to meaningfully assess residents' clinical performance in pediatric emergency medicine using resident-sensitive quality measures (RSQMs). METHOD EHR data for asthma and bronchiolitis RSQMs from Cincinnati Children's Hospital Medical Center, a quaternary children's hospital, between July 1, 2017, and June 30, 2019, were analyzed by ranking residents based on composite scores calculated using raw, unadjusted, and case-mix adjusted latent score models, with lower percentiles indicating a lower quality of care and performance. Reliability and associations between the scores produced by the 3 scoring models were compared. Resident and patient characteristics associated with performance in the highest and lowest tertiles and changes in residents' rank after case-mix adjustments were also identified. RESULTS 274 residents and 1,891 individual encounters of bronchiolitis patients aged 0-1 as well as 270 residents and 1,752 individual encounters of asthmatic patients aged 2-21 were included in the analysis. The minimum reliability requirement to create a composite score was met for asthma data (α = 0.77), but not bronchiolitis (α = 0.17). The asthma composite scores showed high correlations ( r = 0.90-0.99) between raw, latent, and adjusted composite scores. After case-mix adjustments, residents' absolute percentile rank shifted on average 10 percentiles. Residents who dropped by 10 or more percentiles were likely to be more junior, saw fewer patients, cared for less acute and younger patients, or had patients with a longer emergency department stay. CONCLUSIONS For some clinical areas, it is possible to use EHR data, adjusted for patient complexity, to meaningfully assess residents' clinical performance and identify opportunities for quality improvement.
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Affiliation(s)
- Alina Smirnova
- A. Smirnova is clinical assistant professor, Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada, and adjunct assistant professor, Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee, Wisconsin; ORCID: https://orcid.org/0000-0003-4491-3007
| | - Saad Chahine
- S. Chahine is associate professor of measurement and assessment, Faculty of Education, Queen’s University, Kingston, Ontario, Canada; ORCID: https://orcid.org/0000-0003-0488-773X
| | - Christina Milani
- C. Milani is clinical research assistant, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Abigail Schuh
- A. Schuh is associate professor of pediatrics, Division of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; ORCID: http://orcid.org/0000-0002-6422-2361
| | - Stefanie S. Sebok-Syer
- S.S. Sebok-Syer is assistant professor, Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California; ORCID: http://orcid.org/0000-0002-3572-5971
| | - Jordan L. Swartz
- J.L. Swartz is clinical associate professor, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, and director of clinical informatics, Department of Emergency Medicine, NYU Langone Health, New York, New York
| | - Jeffrey A. Wilhite
- J.A. Wilhite is senior research coordinator, Department of Medicine, NYU Langone Health, New York, New York; ORCID: https://orcid.org/0000-0003-4096-8473
| | - Adina Kalet
- A. Kalet is professor and Steven and Shelagh Roell Chair, Robert D. and Patricia P. Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee, Wisconsin; ORCID: http://orcid.org/0000-0003-4855-0223
| | - Steven J. Durning
- S.J. Durning is professor and vice chair, Department of Medicine, and director, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: http://orcid.org/0000-0001-5223-1597
| | - Kiki M.J.M.H. Lombarts
- K.M.J.M.H. Lombarts is professor of professional performance, Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, and Amsterdam Public Health research institute, Amsterdam, The Netherlands; ORCID: https://orcid.org/0000-0001-6167-0620
| | - Cees P.M. van der Vleuten
- C.P.M. van der Vleuten is professor of education, Department of Educational Development and Research. Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands; ORCID: http://orcid.org/0000-0001-6802-3119
| | - Daniel J. Schumacher
- D.J. Schumacher is professor of pediatrics, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: http://orcid.org/0000-0001-5507-8452
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Moazzam Z, Lima HA, Alaimo L, Endo Y, Ejaz A, Beane J, Dillhoff M, Cloyd J, Pawlik TM. Hepatopancreatic Surgeons Versus Pancreatic Surgeons: Does Surgical Subspecialization Impact Patient Care and Outcomes? J Gastrointest Surg 2023; 27:750-759. [PMID: 36857013 DOI: 10.1007/s11605-023-05639-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/18/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Hepatopancreatic (HP) surgeon and hospital procedural volume may vary relative to liver or pancreas cases. We sought to investigate the impact of surgeon and hospital pancreatic subspecialization on patient outcomes. METHODS Patients who underwent pancreatic surgery between 2013-2017 were identified from the Medicare Standard Analytic Files. The surgery subspecialization index (SSI) was calculated to signify surgeon and hospital pancreatic subspecialization, and categorized as low, intermediate, and high SSI. The association of SSI with Textbook Outcome (TO) and its components, failure to rescue (FTR), discharge to home and index admission expenditures was assessed with mixed-effects multivariable logistic regression. RESULTS Among 19,625 patients, most pancreatic procedures were characterized by high SSI (Low SSI: 27.7%, Intermediate SSI: 34.7%, High SSI: 37.7%). Notably, higher SSI was associated with greater odds of achieving a TO [Intermediate SSI: OR 1.16 (95%CI 1.06-1.27); High SSI: OR 1.23 (95%CI 1.11-1.35)] as well as being discharged home, and lower odds of experiencing FTR. Furthermore, this association persisted in both low-volume [referent: Low SSI; Intermediate SSI: OR 1.14 (95%CI 1.01-1.28); High SSI: OR 1.15 (95%CI 1.02-1.31)] and high-volume hospitals [referent: Low SSI; Intermediate SSI: OR 1.16 (95%CI 1.01-1.32); High SSI: OR 1.26 (95%CI 1.09-1.45)]. CONCLUSIONS Greater pancreatic subspecialization was associated with improved postoperative outcomes following pancreatic resection. Amidst increasing efforts to improve quality of care, surgical subspecialization may play a role in determining patient outcomes regardless of total surgeon or hospital volume.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Henrique Araujo Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Joal Beane
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Nakata Y, Watanabe Y, Otake H. Effect of surgeon experience on technical efficiency. Health Serv Manage Res 2023; 36:34-41. [PMID: 35331041 DOI: 10.1177/09514848221080688] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Surgeon experience certainly improves their technical efficiency although it also causes physiological changes with aging. The authors hypothesized that surgeons' technical efficiency improves with increasing experience up to a point where it then decreases, which is a concave relationship. The authors collected data from all the surgical procedures performed at University Hospital from April through September in 2013-19. The dependent variable was defined as surgeons' technical efficiency scores that were calculated using output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis. Inputs were defined as (1) the number of assistants and (2) the duration of surgical operation. The output was defined as the surgical fee for each surgery. Surgeon experience was defined as the number of years since medical school graduation. Five control variables were selected: surgical volume, gender, academic rank, surgical specialty, and the year of surgery. Multiple regression analysis using pooled and random-effects Tobit models was performed for our panel data. Totally 20,375 surgical procedures performed by 264 surgeons in 42 months were analyzed. The coefficients of experience and the square of experience were not significantly different from zero. The other coefficients were also insignificant. Surgeons' technical efficiency does not have a concave relationship with experience.
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Affiliation(s)
- Yoshinori Nakata
- 13148Teikyo University Graduate School of Public Health, Tokyo, Japan.,Teikyo University Medical Information and System Research Center, Tokyo, Japan
| | - Yuichi Watanabe
- Waseda University Graduate School of Economics, Tokyo, Japan
| | - Hiroshi Otake
- Department of Anesthesia, Showa University School of Medicine, Tokyo, Japan
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Holmboe ES, Kogan JR. Will Any Road Get You There? Examining Warranted and Unwarranted Variation in Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1128-1136. [PMID: 35294414 PMCID: PMC9311475 DOI: 10.1097/acm.0000000000004667] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Undergraduate and graduate medical education have long embraced uniqueness and variability in curricular and assessment approaches. Some of this variability is justified (warranted or necessary variation), but a substantial portion represents unwarranted variation. A primary tenet of outcomes-based medical education is ensuring that all learners acquire essential competencies to be publicly accountable to meet societal needs. Unwarranted variation in curricular and assessment practices contributes to suboptimal and variable educational outcomes and, by extension, risks graduates delivering suboptimal health care quality. Medical education can use lessons from the decades of study on unwarranted variation in health care as part of efforts to continuously improve the quality of training programs. To accomplish this, medical educators will first need to recognize the difference between warranted and unwarranted variation in both clinical care and educational practices. Addressing unwarranted variation will require cooperation and collaboration between multiple levels of the health care and educational systems using a quality improvement mindset. These efforts at improvement should acknowledge that some aspects of variability are not scientifically informed and do not support desired outcomes or societal needs. This perspective examines the correlates of unwarranted variation of clinical care in medical education and the need to address the interdependency of unwarranted variation occurring between clinical and educational practices. The authors explore the challenges of variation across multiple levels: community, institution, program, and individual faculty members. The article concludes with recommendations to improve medical education by embracing the principles of continuous quality improvement to reduce the harmful effect of unwarranted variation.
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Affiliation(s)
- Eric S. Holmboe
- E.S. Holmboe is chief, research, milestones development, and evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-0108-6021
| | - Jennifer R. Kogan
- J.R. Kogan is associate dean, Student Success and Professional Development, and professor of medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0001-8426-9506
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Reule S, Foley R, Shaughnessy D, Drawz P, Ishani A, Rosenberg M. Does experience matter? The relationship between nephrologist characteristics and end stage kidney disease patient outcomes. Hemodial Int 2022; 26:114-123. [PMID: 34227221 PMCID: PMC8724381 DOI: 10.1111/hdi.12961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nephrology offers the unique opportunity to directly link patients to providers, allowing the study of patient outcomes at the provider level. The purpose of this analysis was to determine whether nephrologist experience, defined as years in nephrology practice, was associated with clinical outcomes. DESIGN Physician data contained within the American Medical Association (AMA) Physician Masterfile was combined with patient and Medicare claims data from the United States Renal Data System (USRDS) for the calendar year 2012, with follow up extending through June 30, 2014. Associations with important healthcare outcomes including mortality in patients receiving maintenance renal replacement therapy (RRT), waitlisting for kidney transplantation, and receipt of a kidney transplant were determined with broad adjustment for both patient and provider level variables, with attention on tertile of provider time in practice. RESULTS We identified 256,324 patients on maintenance RRT cared for by 6193 nephrologists. Nephrologists with the least experience were more likely to be female, reside in a region with ≥1,000,000 people, have a Doctor of Osteopathic Medicine degree, and have a listed maintenance of certification status as "yes." Overall, 30.2% of the cohort died at a mean follow up of 1.99 years. Compared to those with the 0-10 years of experience, receipt of care from nephrologists with more experience was associated with lower mortality (AHR 0.97 CI 0.94-0.99 for nephrologists with 11-20 years) and increased listing for kidney transplantation (AHR 1.10; CI 1.01-1.21 for nephrologists with >21 years experience). Experience level did not result in a difference in kidney transplantation rates. CONCLUSIONS Receipt of maintenance RRT from nephrologists with greater experience was associated with decreased mortality and increased listing for kidney transplantation, an effect that remained significant after multiple adjustments for important patient and nephrologist variables.
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Affiliation(s)
- Scott Reule
- Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Robert Foley
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Shaughnessy
- School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Paul Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Areef Ishani
- Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Mark Rosenberg
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Ajmi SC, Aase K. Physicians' clinical experience and its association with healthcare quality: a systematised review. BMJ Open Qual 2021; 10:e001545. [PMID: 34740896 PMCID: PMC8573657 DOI: 10.1136/bmjoq-2021-001545] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/22/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE There is conflicting evidence regarding whether physicians' clinical experience affects healthcare quality. Knowing whether an association exists and which dimensions of quality might be affected can help healthcare services close quality gaps by tailoring improvement initiatives according to physicians' clinical experience. Here, we present a systematised review that aims to assess the potential association between physicians' clinical experience and different dimensions of healthcare quality. METHODS We conducted a systematised literature review, including the databases MEDLINE, Embase, PsycINFO and PubMed. The search strategy involved combining predefined terms that describe physicians' clinical experience with terms that describe different dimensions of healthcare quality (ie, safety, clinical effectiveness, patient-centredness, timeliness, efficiency and equity). We included relevant, original research published from June 2004 to November 2020. RESULTS Fifty-two studies reporting 63 evaluations of the association between physicians' clinical experience and healthcare quality were included in the final analysis. Overall, 27 (43%) evaluations found a positive or partially positive association between physicians' clinical experience and healthcare quality; 22 (35%) found no association; and 14 (22%) evaluations reported a negative or partially negative association. We found a proportional association between physicians' clinical experience and quality regarding outcome measures that reflect safety, particularly in the surgical fields. For other dimensions of quality, no firm evidence was found. CONCLUSION We found no clear evidence of an association between measures of physicians' clinical experience and overall healthcare quality. For outcome measures related to safety, we found that physicians' clinical experience was proportional with safer care, particularly in surgical fields. Our findings support efforts to secure adequate training and supervision for early-career physicians regarding safety outcomes. Further research is needed to reveal the potential subgroups in which gaps in quality due to physicians' clinical experience might exist.
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Affiliation(s)
- Soffien Chadli Ajmi
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Karina Aase
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- SHARE Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Alweis R, Donato A, Terry R, Goodermote C, Qadri F, Mayo R. Benefits of developing graduate medical education programs in community health systems. J Community Hosp Intern Med Perspect 2021; 11:569-575. [PMID: 34567443 PMCID: PMC8462840 DOI: 10.1080/20009666.2021.1961381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The creation of new CMS-funded Graduate Medical Education (GME) cap positions by the Consolidated Appropriations Act 2021 offers a unique opportunity for systems in community and rural settings to develop and expand their training programs. This article provides a review of the evidence behind the value proposition for system administrators to foster the growth of GME in community health systems. The infrastructure needed to accredit GME programs may reduce the cost of care for both the patients and the system through improved patient outcomes and facilitation of system efforts to recognize and mitigate social determinants of health. Residents, fellows and medical students expand the capacity of the current healthcare workforce of a system by providing coverage during healthcare emergencies and staffing services in difficult-to-recruit specialties. Those trainees are the nucleus of succession planning for the current medical staff, can facilitate the creation and expansion of service lines, and may elevate the profile of the system through scholarly work and equity and quality improvement activities. While creating GME programs in a community health system may, at first glance, be perceived as cost-prohibitive, there are robust advantages to a system for their creation.
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Affiliation(s)
- Richard Alweis
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Anthony Donato
- Department of Medicine, Tower Health, West Reading, Pennsylvania, United States
| | - Richard Terry
- Academic Affairs, Lake Erie College of Medicine at Elmira, Elmira, New York, United States
| | - Christina Goodermote
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Farrah Qadri
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Robert Mayo
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
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Binder W, Abrahams CO, Fox JM, Nestor E, Baird J. The age-old question: Thematic analysis of focus groups on physician experiences of aging in emergency medicine. J Am Coll Emerg Physicians Open 2021; 2:e12499. [PMID: 34258608 PMCID: PMC8256805 DOI: 10.1002/emp2.12499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/23/2021] [Accepted: 06/15/2021] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Emergency medicine has a demanding work environment. Characteristics influencing longevity among older physicians in emergency medicine have been the subject of ongoing discussion. The American College of Emergency Physicians (ACEP) released a policy statement in 2009 suggesting accommodating emergency physicians in preretirement years. We engaged emergency physicians to determine awareness of the ACEP policy and issues faced in preretirement years. METHODS We conducted a series of online focus group discussions with a purposive sample of emergency physicians, age ≥ 50 years. The discussion guide was developed from the ACEP policy statement and relevant literature. Groups were audio recorded, transcribed, and analyzed with a thematic coding system developed iteratively by the 4-person team. Emerging themes were identified, organized, and presented with illustrative quotations. RESULTS A total of 28 emergency physicians participated in 4 focus groups, with between 6 and 9 participants in each group. These physicians had between 17 and 35 years of clinical experience (median = 27), 6 were female (21%), and the majority (n = 26, 93%) worked in academic emergency medicine. Only 1 emergency physician was fully aware of the ACEP policy. Three principal content areas were identified: workload demands that change as physicians age, wellness and physician social equity, and senior emergency physician value. Interwoven across all of these was the focus on leadership and solutions to issues. Issues facing emergency physicians in their preretirement years were identified; commitment from emergency medicine site and national leadership and buy-in from junior colleagues was emphasized. Generational conflicts in recognizing the contribution and needs of preretirement emergency physicians was a major barrier to solutions. CONCLUSIONS Workload demands, wellness and physician social equity, and concerns about value as a senior physician are major themes confronting preretirement emergency physicians. Generational divides, deficits in local and national leadership, and the health detriments of rotating schedules and night shifts are barriers to longevity in emergency medicine. Further research on the value of senior physicians and the impact of hospital and departmental financial models on adopting accommodations for senior emergency physicians is needed.
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Affiliation(s)
- William Binder
- Department of Emergency Medicine, Warren Alpert Medical SchoolBrown UniversityProvidenceRhode IslandUSA
| | - Casey O. Abrahams
- Warren Alpert Medical SchoolBrown UniversityProvidenceRhode IslandUSA
| | - Jordan M. Fox
- Warren Alpert Medical SchoolBrown UniversityProvidenceRhode IslandUSA
| | - Elizabeth Nestor
- Department of Emergency Medicine, Warren Alpert Medical SchoolBrown UniversityProvidenceRhode IslandUSA
| | - Janette Baird
- Department of Emergency Medicine, Warren Alpert Medical SchoolBrown UniversityProvidenceRhode IslandUSA
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Caretta-Weyer HA, Chan T, Bigham BL, Kinnear B, Huwendiek S, Schumacher DJ. If we could turn back time: Imagining time-variable, competency-based medical education in the context of COVID-19. MEDICAL TEACHER 2021; 43:774-779. [PMID: 34027813 DOI: 10.1080/0142159x.2021.1925641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The COVID-19 pandemic has exposed a paradox in historical models of medical education: organizations responsible for applying consistent standards for progression have needed to adapt to training environments marked by inconsistency and change. Although some institutions have maintained their traditional requirements, others have accelerated their programs to rush nearly graduated trainees to the front lines. One interpretation of the unplanned shortening of the duration of training programs during a crisis is that standards have been lowered. But it is also possible that these trainees were examined according to the same standards as usual and were judged to have already met them. This paper discusses the impacts of the COVID-19 pandemic on the current workforce, provides an analysis of how competency-based medical education (CBME) in the context of the pandemic might have mitigated wide-scale disruption, and identifies structural barriers to achieving an ideal state. The paper further calls upon universities, health centres, governments, certifying bodies, regulatory authorities, and health care professionals to work collectively on a truly time-variable model of CBME. The pandemic has made clear that time variability in medical education already exists and should be adopted widely and formally. If our systems today had used a framework of outcome competencies, sequenced progression, tailored learning, focused instruction, and programmatic assessment, we may have been even more nimble in changing our systems to care for our patients with COVID-19.
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Affiliation(s)
| | - Teresa Chan
- Department of Medicine, McMaster University, Hamilton, Canada
- McMaster Program for Education Research, Innovation, and Theory (MERIT), Hamilton, Canada
| | - Blair L Bigham
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | - Benjamin Kinnear
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sören Huwendiek
- Department for Assessment and Evaluation, Institute for Medical Education, University of Bern, Bern, Switzerland
| | - Daniel J Schumacher
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Emergency Medicine, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Riordan F, McHugh SM, O'Donovan C, Mtshede MN, Kearney PM. The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:1836-1848. [PMID: 32016700 PMCID: PMC7280455 DOI: 10.1007/s11606-020-05676-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/03/2019] [Accepted: 01/19/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources. METHODS We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis. RESULTS In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care. DISCUSSION Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.
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Affiliation(s)
- F Riordan
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland.
| | - S M McHugh
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | | | - Mavis N Mtshede
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - P M Kearney
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
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Sentilhes L, Madar H, Ducarme G, Hamel JF, Mattuizzi A, Hanf M. Outcomes of operative vaginal delivery managed by residents under supervision and attending obstetricians: a prospective cross-sectional study. Am J Obstet Gynecol 2019; 221:59.e1-59.e15. [PMID: 30807764 DOI: 10.1016/j.ajog.2019.02.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND To assess both severe maternal and neonatal mortality and morbidity after attempted operative vaginal deliveries by residents under supervision and by attending obstetricians. STUDY DESIGN Secondary analysis of a 5-year prospective study with cross-sectional analysis including 2192 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. Obstetricians who attempted or performed an operative vaginal delivery were classified into 2 groups according to their level of experience: attending obstetricians (who had 5 years or more of experience) and obstetric residents (who had less than 5 years of experience) under the supervision of an attending obstetrician. We used multivariate logistic regression and propensity score methods to compare outcomes associated with attending obstetricians and obstetric residents. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesareans, postpartum hemorrhage >1500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, or maternal death; severe neonatal morbidity was defined as a 5-minute Apgar score <7, umbilical artery pH <7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, or neonatal death. RESULTS High prepregnancy body mass index, high dose of oxytocin, manual rotation, persistent occiput posterior or transverse positions, operating room delivery, midpelvic delivery, forceps, and spatulas were significantly more frequent in deliveries managed by attending obstetricians than residents whereas a second-stage pushing phase longer than 30 minutes was significantly more frequent in deliveries managed by residents. The rate of severe maternal morbidity was 7.8% (115/1475) for residents vs 9.9% (48/484) for attending obstetricians; for severe neonatal morbidity, the rates were 8.3% (123/1475) vs 15.1% (73/484), respectively. In the univariate, multivariable, and sensitivity analyses, attempted operative vaginal delivery managed by a resident was significantly and inversely associated with severe neonatal but not maternal morbidity. After propensity score matching, delivery managed by a resident was not significantly associated with severe maternal morbidity (adjusted odds ratio, 0.74; 95% confidence interval, 0.39-1.38) and was no longer associated with neonatal morbidity (adjusted odds ratio, 0.51; 95% confidence interval, 0.25-1.04). CONCLUSION Management of attempted operative vaginal deliveries by residents under the supervision of attending obstetricians, compared with by the attending obstetricians themselves, does not appear to be associated with either maternal or neonatal morbidity. These reassuring results support the continued use of residency programs for training in operative vaginal deliveries under the supervision of attending obstetricians.
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Abstract
RATIONALE Physicians are increasingly being held accountable for patient outcomes, yet their specific contribution to the outcomes remains uncertain. OBJECTIVES To determine variation in outcomes of mechanically ventilated patients among intensivists, as well as associations between intensivist experience and patient outcomes. METHODS We performed a retrospective cohort study of mechanically ventilated Medicare fee-for-service patients in acute care hospitals in Pennsylvania using administrative, clinical, and physician data from Centers for Medicare and Medicaid Services and the American Medical Association from 2008 and 2009. We identified intensivists by training background, board certification, and claims for services provided to patients admitted to an intensive care unit. We assigned patients to intensivists for outcome attribution based on submitted claims for critical care and in-patient services. We estimated the physician-specific adjusted odds ratios (ORs) for 30-day mortality using a hierarchical model with a random effect for physician, adjusted for patient and hospital characteristics. We tested for independent association of physician experience with patient outcomes using mixed-effects regression for the primary outcome of 30-day mortality. We defined physician experience in two ways: years since training completion ("duration") and annual number of mechanically ventilated patients ("volume"). RESULTS We assigned 345 physicians to 11,268 patients. The 30-day mortality was 43% and median hospital length of stay was 11 days (interquartile range = 6-18). The physician adjusted OR varied from 0.72 to 1.64 (median = 0.99; interquartile range = 0.92-1.09). A total of 48% of physicians was outliers, with an adjusted OR significantly different from 1. However, among intensivists, physician experience was not associated with 30-day mortality (duration OR = 1.00 per additional year; 95% confidence interval = 1.00-1.01; volume OR = 1.00 per additional patient; 95% confidence interval = 1.00-1.00). CONCLUSIONS Intensivists independently contribute to outcomes of Medicare patients who undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across intensivists. However, physician experience does not underlie this relationship between intensivists, suggesting the need to identify modifiable physician factors to improve outcomes.
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Rosenberg ME. Toward More Meaningful Accountability to the Public: Assessing Lifelong Competence of Physicians. Clin J Am Soc Nephrol 2018; 13:167-169. [PMID: 29018098 PMCID: PMC5753318 DOI: 10.2215/cjn.07570717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Mark E Rosenberg
- Division of Renal Diseases and Hypertension, University of Minnesota Medical School, Minneapolis, Minnesota
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ROSENBERG MARKE. AN OUTCOMES-BASED APPROACH ACROSS THE MEDICAL EDUCATION CONTINUUM. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2018; 129:325-340. [PMID: 30166726 PMCID: PMC6116626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The medical education continuum spans undergraduate medical education (i.e., medical school), graduate medical education (i.e., residency and fellowship), and continuing medical education. This article provides three examples across the medical education and practice continuum where an outcomes-based approach is being used. By focusing on outcomes instead of process, a more predictable product of undergraduate medical education will be a medical student capable on day 1 of performing the work required of residency. Assessing the quality of medical education by the quality of care a graduate delivers once they enter practice will allow more effective design of medical education to improve care. A more comprehensive assessment of lifelong physician competence will help ensure the health of patients, their health care experience, and the value of care are of the highest possible standard and are continually improving.
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MESH Headings
- Clinical Clerkship
- Clinical Competence
- Competency-Based Education
- Curriculum
- Education, Medical, Continuing/methods
- Education, Medical, Continuing/standards
- Education, Medical, Graduate/methods
- Education, Medical, Graduate/standards
- Education, Medical, Undergraduate/methods
- Education, Medical, Undergraduate/standards
- Humans
- Outcome Assessment, Health Care/methods
- Outcome Assessment, Health Care/standards
- Quality Improvement
- Quality Indicators, Health Care
- Treatment Outcome
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Affiliation(s)
- MARK E. ROSENBERG
- Correspondence and reprint requests: Mark E. Rosenberg, MD, University of Minnesota Medical School,
420 Delaware Street S.E., MMC 293, Minneapolis, Minnesota 55455612-626-9596
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Smirnova A, Ravelli ACJ, Stalmeijer RE, Arah OA, Heineman MJ, van der Vleuten CPM, van der Post JAM, Lombarts KMJMH. The Association Between Learning Climate and Adverse Obstetrical Outcomes in 16 Nontertiary Obstetrics-Gynecology Departments in the Netherlands. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:1740-1748. [PMID: 28953570 DOI: 10.1097/acm.0000000000001964] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE To investigate the association between learning climate and adverse perinatal and maternal outcomes in obstetrics-gynecology departments. METHOD The authors analyzed 23,629 births and 103 learning climate evaluations from 16 nontertiary obstetrics-gynecology departments in the Netherlands in 2013. Multilevel logistic regressions were used to calculate the odds of adverse perinatal and maternal outcomes, by learning climate score tertile, adjusting for maternal and department characteristics. Adverse perinatal outcomes included fetal or early neonatal mortality, five-minute Apgar score < 7, or neonatal intensive care unit admission for ≥ 24 hours. Adverse maternal outcomes included postpartum hemorrhage and/or transfusion, death, uterine rupture, or third- or fourth-degree perineal laceration. Bias analyses were conducted to quantify the sensitivity of the results to uncontrolled confounding and selection bias. RESULTS Learning climate scores were significantly associated with increased odds of adverse perinatal outcomes (aOR 2.06, 95% CI 1.14-3.72). Compared with the lowest tertile, departments in the middle tertile had 46% greater odds of adverse perinatal outcomes (aOR 1.46, 95% CI 1.09-1.94); departments in the highest tertile had 69% greater odds (aOR 1.69, 95% CI 1.24-2.30). Learning climate was not associated with adverse maternal outcomes (middle vs. lowest tertile: OR 1.04, 95% CI 0.93-1.16; highest vs. lowest tertile: OR 0.98, 95% CI 0.88-1.10). CONCLUSIONS Learning climate was associated with significantly increased odds of adverse perinatal, but not maternal, outcomes. Research in similar clinical contexts is needed to replicate these findings and explore potential mechanisms behind these associations.
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Affiliation(s)
- Alina Smirnova
- A. Smirnova is a PhD candidate, School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands, and researcher, Professional Performance Research Group, Institute for Education and Training, Academic Medical Center, Amsterdam, The Netherlands. A.C.J. Ravelli is epidemiologist and assistant professor, Departments of Medical Informatics and Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands. R.E. Stalmeijer is assistant professor, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands. O.A. Arah is professor, Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California. M.J. Heineman is professor, Board of Directors, Academic Medical Center, Amsterdam, The Netherlands. C.P.M. van der Vleuten is professor and scientific director, School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands. J.A.M. van der Post is professor, Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands. K.M.J.M.H. Lombarts is professor, Professional Performance Research Group, Institute for Education and Training, Academic Medical Center, Amsterdam, The Netherlands
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Kogan JR, Hatala R, Hauer KE, Holmboe E. Guidelines: The do's, don'ts and don't knows of direct observation of clinical skills in medical education. PERSPECTIVES ON MEDICAL EDUCATION 2017; 6:286-305. [PMID: 28956293 PMCID: PMC5630537 DOI: 10.1007/s40037-017-0376-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Direct observation of clinical skills is a key assessment strategy in competency-based medical education. The guidelines presented in this paper synthesize the literature on direct observation of clinical skills. The goal is to provide a practical list of Do's, Don'ts and Don't Knows about direct observation for supervisors who teach learners in the clinical setting and for educational leaders who are responsible for clinical training programs. METHODS We built consensus through an iterative approach in which each author, based on their medical education and research knowledge and expertise, independently developed a list of Do's, Don'ts, and Don't Knows about direct observation of clinical skills. Lists were compiled, discussed and revised. We then sought and compiled evidence to support each guideline and determine the strength of each guideline. RESULTS A final set of 33 Do's, Don'ts and Don't Knows is presented along with a summary of evidence for each guideline. Guidelines focus on two groups: individual supervisors and the educational leaders responsible for clinical training programs. Guidelines address recommendations for how to focus direct observation, select an assessment tool, promote high quality assessments, conduct rater training, and create a learning culture conducive to direct observation. CONCLUSIONS High frequency, high quality direct observation of clinical skills can be challenging. These guidelines offer important evidence-based Do's and Don'ts that can help improve the frequency and quality of direct observation. Improving direct observation requires focus not just on individual supervisors and their learners, but also on the organizations and cultures in which they work and train. Additional research to address the Don't Knows can help educators realize the full potential of direct observation in competency-based education.
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Affiliation(s)
- Jennifer R Kogan
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Rose Hatala
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Karen E Hauer
- University of California San Francisco, San Francisco, CA, USA
| | - Eric Holmboe
- Accreditation Council of Graduate Medical Education, Chicago, IL, USA
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Anderson BR, Wallace AS, Hill KD, Gulack BC, Matsouaka R, Jacobs JP, Bacha EA, Glied SA, Jacobs ML. Association of Surgeon Age and Experience With Congenital Heart Surgery Outcomes. Circ Cardiovasc Qual Outcomes 2017; 10:e003533. [PMID: 28710297 PMCID: PMC5656266 DOI: 10.1161/circoutcomes.117.003533] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/09/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgeon experience concerns both families of children with congenital heart disease and medical providers. Relationships between surgeon seniority and patient outcomes are often assumed, yet there are little data. METHODS AND RESULTS This national study used linked data from the American Medical Association Physician Masterfile and the Society of Thoracic Surgeons-Congenital Heart Surgery Database to examine associations between surgeon years since medical school and major morbidity/mortality for children undergoing cardiac surgery. Sensitivity analyses explored the effects of patient characteristics, institutional/surgeon volumes, and various measures of institutional surgeon team experience. In secondary analyses, major morbidity and mortality were examined as separate end points. We identified 206 congenital heart surgeons from 91 centers performing 62 851 index operations (2010-2014). Median time from school was 25 years (range 9-55 years). A major morbidity/mortality occurred in 11.5% of cases. In multivariable analyses, the odds of major morbidity/mortality were similar for early-career (<15 years from medical school, ≈<40 years old), midcareer (15-24 years, ≈40-50 years old), and senior surgeons (25-35 years, ≈50-60 years old). The odds of major morbidity/mortality were ≈25% higher for operations performed by very senior surgeons (35-55 years from school, ≈60-80 years old; n=9044 cases). Results were driven by differences in morbidity. In extensive sensitivity analyses, these effects remained constant. CONCLUSIONS In this study of >200 congenital heart surgeons, we found patient outcomes for surgeons with the fewest years of experience to be comparable to those of their midcareer and senior colleagues, within the context of existing referral and support practices. Very senior surgeons had higher risk-adjusted odds of major morbidity/mortality. Contemporary approaches to training, referral, mentoring, surgical planning, and other support practices might contribute to the observed outcomes of junior congenital heart surgeons being comparable to those of more experienced colleagues. Understanding and disseminating these practices might benefit the medical community at large.
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Affiliation(s)
- Brett R Anderson
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.).
| | - Amelia S Wallace
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Kevin D Hill
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Brian C Gulack
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Roland Matsouaka
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Jeffrey P Jacobs
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Emile A Bacha
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Sherry A Glied
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Marshall L Jacobs
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
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Tsugawa Y, Newhouse JP, Zaslavsky AM, Blumenthal DM, Jena AB. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ 2017; 357:j1797. [PMID: 28512089 PMCID: PMC5431772 DOI: 10.1136/bmj.j1797] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objectives To investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians.Design Observational study.Setting US acute care hospitals.Participants 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists.Main outcome measures 30 day mortality and readmissions and costs of care. Results 736 537 admissions managed by 18 854 hospitalist physicians (median age 41) were included. Patients' characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients' adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% confidence interval 10.7% to 10.9%), 11.1% for physicians aged 40-49 (11.0% to 11.3%), 11.3% for physicians aged 50-59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses.Conclusions Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients.
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Affiliation(s)
- Yusuke Tsugawa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Joseph P Newhouse
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Harvard Kennedy School, Cambridge, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Asch DA, Nicholson S, Srinivas SK, Herrin J, Epstein AJ. How do you deliver a good obstetrician? Outcome-based evaluation of medical education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:24-6. [PMID: 24280859 DOI: 10.1097/acm.0000000000000067] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The goal of medical education is the production of a workforce capable of improving the health and health care of patients and populations, but it is hard to use a goal that lofty, that broad, and that distant as a standard against which to judge the success of schools or training programs or particular elements within them. For that reason, the evaluation of medical education often focuses on elements of its structure and process, or on the assessment of competencies that could be considered intermediate outcomes. These measures are more practical because they are easier to collect, and they are valuable when they reflect activities in important positions along the pathway to clinical outcomes. But they are all substitutes for measuring whether educational efforts produce doctors who take good care of patients.The authors argue that the evaluation of medical education can become more closely tethered to the clinical outcomes medical education aims to achieve. They focus on a specific clinical outcome-maternal complications of obstetrical delivery-and show how examining various observable elements of physicians' training and experience helps reveal which of those elements lead to better outcomes. Does it matter where obstetricians trained? Does it matter how much experience they have? Does it matter how good they were to start? Each of these questions reflects a component of the production of a good obstetrician and, most important, defines a good obstetrician as one whose patients in the end do well.
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Affiliation(s)
- David A Asch
- Dr. Asch is a physician, Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, professor, Perelman School of Medicine and Wharton School, University of Pennsylvania, and executive director, Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania. Dr. Nicholson is professor, Department of Policy Analysis and Management, Cornell University, Ithaca, New York, and research associate, National Bureau of Economic Research, Cambridge, Massachusetts. Dr. Srinivas is assistant professor of obstetrics and gynecology, Division of Maternal Fetal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Herrin is assistant professor of cardiology, Yale School of Medicine, Yale University, New Haven, Connecticut, and senior statistician, Health Research & Educational Trust, Chicago, Illinois. Dr. Epstein is health science specialist, Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, and research associate professor, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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