The learners' perceptions survey-primary care: assessing resident perceptions of internal medicine continuity clinics and patient-centered care

The Impact of Changing From a 6+2 to a 3+1 Residency Block Schedule on Patient Access and Other Outcomes

Background The "X+Y" residency scheduling model includes "X" weeks of uninterrupted inpatient or subspecialty rotations, followed by "Y" week(s) of uninterrupted outpatient rotations. The optimal ratio of X to Y is unclear. Objective Determine the impact of moving from a 6+2 to a 3+1 schedule on patient access to care, perceived quality of care, and resident/faculty satisfaction. Methods Our residency program switched from a 6+2 to a 3+1 scheduling model in July 2018. We measured access to care before and after the change using the "third next available" (TNA) metric. In June 2019, we administered a voluntary, anonymous, 20-item survey to residents, staff, and faculty who worked in resident clinic in both the 6+2 and 3+1 years. Results Patient access to appointments with their resident physician, as measured by TNA, improved significantly after the schedule change (mean 34.1 days in 6+2, mean 26.5 days in 3+1, P<.0001). Fifteen of 17 (88%) eligible residents and 13 of 24 (54%) faculty/staff filled out the voluntary anonymous survey. Surveyed residents and faculty/staff had concordant perception that the schedule change led to improvement in patient continuity, quality of care, and ability of residents to follow up on diagnostic tests and have regular interaction with clinic attendings. However, residents did not report a change in satisfaction with continuity clinic. Conclusions Changing from a 6+2 to a 3+1 schedule was associated with improvement in patient access to care. Residents and faculty/staff perceived that this schedule change improved several aspects of patient care.

Impacts of an Electronic Health Record Transition on Veterans Health Administration Health Professions Trainee Experience

BACKGROUND

Adoption of electronic health care records (EHRs) has proliferated since 2000. While EHR transitions are widely understood to be disruptive, little attention has been paid to their effect on health professions trainees' (HPTs) ability to learn and conduct work. Veterans Health Administration's (VA) massive transition from its homegrown EHR (CPRS/Vista) to the commercial Oracle Cerner presents an unparalleled-in-scope opportunity to gain insight on trainee work functions and their ability to obtain requisite experience during transitions.

OBJECTIVE

To identify how an organizational EHR transition affected HPT work and learning at the third VA go-live site.

DESIGN

A formative mixed-method evaluation of HPT experiences with VHA's EHR transition including interviews with HPTs and supervisors at Chalmers P. Wylie VA Outpatient Clinic in Columbus, OH, before (~60 min), during (15-30 min), and after (~60 min) go-live (December 2021-July 2022). We also conducted pre- (March 2022-April 2022) and post-go live (May 2022-June 2022) HPT and employee surveys.

PARTICIPANTS

We conducted 24 interviews with HPTs (n=4), site leaders (n=2), and academic affiliates (n=2) using snowball sampling. We recruited HPTs in pre- (n=13) and post-go-live (n=10) surveys and employees in pre- (n=408) and post-go-live (n=458) surveys.

APPROACH

We conducted interviews using a semi-structured guide and grounded prompts. We coded interviews and survey free text data using a priori and emergent codes, subsequently conducting thematic analysis. We conducted descriptive statistical analysis of survey responses and merged interview and survey data streams.

KEY RESULTS

Our preliminary findings indicate that the EHR transition comprehensively affected HPT experiences, disrupting processes from onboarding and training to clinical care contributions and training-to-career retention.

CONCLUSIONS

Understanding HPTs' challenges during EHR transitions is critical to effective training. Mitigating the identified barriers to HPT training and providing patient care may lessen their dissatisfaction and ensure quality patient care during EHR transitions.

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

PURPOSE

The primary care physician shortage in the United States presents significant challenges for health systems seeking to maintain a sufficient primary care workforce. Perspectives on training or working in primary care in the Veterans Health Administration (VHA) may yield insights into strategic recruitment to make the VHA and other health systems more attractive to primary care physicians. The authors sought to understand the experiences of resident and staff physicians with limited tenure within VHA primary care to identify factors to guide health systems in improving recruitment and retention.

METHOD

This qualitative exploratory study was conducted from June 2018 to October 2019 with 24 internal medicine residents and 30 staff physicians in VHA primary care. Heterogeneity was ensured by sampling for geographical region, rurality, and gender within each cohort. The authors conducted semistructured interviews to ascertain perspectives on training and employment preferences at VHA and non-VHA sites. Combined content analysis was used to generate findings.

RESULTS

The authors identified 4 key themes, centered around shared values and the VHA's mission-driven culture: the VHA "community" was perceived as unique and a major contributor to job satisfaction; facility-level leadership support was important to perceptions of workplace culture around harassment; the VHA primary care delivery model allowed residents and staff physicians to get patients needed care but did not always live up to its potential; and VHA employment was better than expected, but the process of getting hired was a challenge.

CONCLUSIONS

Mission and workplace culture may serve important roles in the desirability of health systems for prospective physicians and the job satisfaction of physicians who work in these systems. Physician recruitment efforts based on these attributes may yield the most success in maintaining a sufficient physician workforce.

Calibration Bias and the Interpretation of Clinical Learning Environment Perceptions Surveys

BACKGROUND

The clinical learning environment (CLE) is frequently assessed using perceptions surveys, such as the AAMC Graduation Questionnaire and ACGME Resident/Fellow Survey. However, these survey responses often capture subjective factors not directly related to the trainee's CLE experiences.

OBJECTIVE

The authors aimed to assess these subjective factors as "calibration bias" and show how it varies by health professions education discipline, and co-varies by program, patient-mix, and trainee factors.

METHODS

We measured calibration bias using 2011-2017 US Department of Veterans Affairs (VA) Learners' Perceptions Survey data to compare medical students and physician residents and fellows (n = 32 830) with nursing (n = 29 758) and allied and associated health (n = 27 092) trainees.

RESULTS

Compared to their physician counterparts, nursing trainees (OR 1.31, 95% CI 1.22-1.40) and allied/associated health trainees (1.18, 1.12-1.24) tended to overrate their CLE experiences. Across disciplines, respondents tended to overrate CLEs when reporting 1 higher level (of 5) of psychological safety (3.62, 3.52-3.73), 1 SD more time in the CLE (1.05, 1.04-1.07), female gender (1.13, 1.10-1.16), 1 of 7 lower academic level (0.95, 1.04-1.07), and having seen the lowest tercile of patients for their respective discipline who lacked social support (1.16, 1.12-1.21) and had low income (1.05, 1.01-1.09), co-occurring addictions (1.06, 1.02-1.10), and mental illness (1.06, 1.02-1.10).

CONCLUSIONS

Accounting for calibration bias when using perception survey scores is important to better understand physician trainees and the complex clinical learning environments in which they train.