The Courteous Consult: A CONSULT Card and Training to Improve Resident Consults

Teaching during Consults: Effects of Multiple Educational Interventions on Satisfaction with Consultant Interactions among Internal Medicine Residents

OBJECTIVE

To evaluate the effect of an educational intervention on Internal Medicine residents' satisfaction with the inpatient consultation process.

METHODS

We hosted an optional workshop for Internal Medicine residents on placing and responding to consults using two memory aid tools. We then provided copies of these memory aids to residents on inpatient Medicine and Infectious Diseases teams, and later surveyed all of the residents who were finishing their inpatient Medicine rotation. Surveys assessed residents' participation in the workshop, receipt of the memory-aid tools, and satisfaction with Infectious Diseases consultation using a 5-point Likert scale. Residents were organized into the following groups: group 1 residents were exposed to the workshop and both memory aid tools; group 2 residents were exposed only to the "responding to consults" memory aid tool; group 3 residents were exposed to the workshop and the "placing consults" memory aid tool; and group 4 residents were not exposed to any interventions. We compared the percentage of satisfied residents among groups.

RESULTS

A total of 36 out of 69 residents answered our survey (response rate of 52%). Among survey respondents, 7 (19.4%) were in group 1, 8 (22.2%) in group 2, 10 (27.8%) in group 3, and 11 (30.6%) in group 4. Group 4 residents had lower satisfaction with the overall consultation process (36.4% residents satisfied vs 90%-100% in the intervention groups, P < 0.001), the consultant's professionalism (54.5% vs 100%, P = 0.002), communication between the primary team and the consultant (54.5% vs 90%-100%, P = 0.01), and teaching received from the consultant (18.2% vs 57.1%-80.0%, P = 0.02).

CONCLUSIONS

An educational workshop and use of structured memory aids can lead to improved resident satisfaction with the consultation process.

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.

Improving Inpatient Consult Communication Through a Standardized Tool

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Core EPAs in the Acting Internship: Early Outcomes from an Interdepartmental Experience

INTRODUCTION

The Core Entrustable Professional Activities for Entering Residency (Core EPAs) are clinical activities all interns should be able to perform on the first day of residency with indirect supervision. The acting (sub) internship (AI) rotation provides medical students the opportunity to be assessed on advanced Core EPAs.

MATERIALS AND METHODS

All fourth-year AI students were taught Core EPA skills and performed these clinical skills under direct supervision. Formative feedback and direct observation data were provided via required workplace-based assessments (WBAs). Supervising physicians rated learner performance using the Ottawa Clinic Assessment Tool (OCAT). WBA and pre-post student self-assessment data were analyzed to assess student performance and gauge curriculum efficacy.

RESULTS

In the 2017-2018 academic year, 167 students completed two AI rotations at our institution. By their last WBA, 91.2% of students achieved a target OCAT supervisory scale rating for both patient handoffs and calling consults. Paired sample t tests of the student pre-post surveys showed statistically significant improvement in self-efficacy on key clinical functions of the EPAs.

DISCUSSION

This study demonstrates that the AI rotation can be structured to include a Core EPA curriculum that can assess student performance utilizing WBAs of directly observed clinical skills.

CONCLUSIONS

Our clinical outcomes data demonstrates that the majority of fourth-year medical students are capable of performing advanced Core EPAs at a level acceptable for intern year by the conclusion of their AI rotations. WBA data collected can also aid in ad hoc and longitudinal summative Core EPA entrustment decisions.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01208-y.

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.

Developing a communication curriculum for primary and consulting services

Communication skills are fundamental to effective patient care, and inter-subspecialty communication is frequently identified as a key component of medical education curriculums globally. The team primarily responsible for a patient, the 'primary service', may often request a consult from a specialist, the 'consulting service', for questions of diagnosis, management, or assistance in arranging or performing a procedure or test. Few resources exist to support the development and growth of communication curriculums across primary and consulting services. We provide tips to improve communication across services in patient care and enhance learning for multiple levels of providers. This article provides a guide for the planning and implementation of a communication curriculum and highlights key components for success, based on our experience as teaching faculty on primary and consulting services, at a large academic institution. With the proper collaborations, teaching touch points, specialist consult communication tool, peer coaches, and timely feedback, this course can meet numerous educational and institutional priorities.

Expanding Telehealth Competencies in Primary Care: A Longitudinal Interdisciplinary Simulation to Train Internal Medicine Residents in Complex Patient Care

BACKGROUND

Despite increasing use of telehealth, there are limited published curricula training primary care providers in utilizing telehealth to deliver complex interdisciplinary care.

OBJECTIVE

To describe and evaluate a telehealth curriculum with a longitudinal objective structured clinical examination (OSCE) to improve internal medicine residents' confidence and skills in coordinating complex interdisciplinary primary care via televisits, electronic consultation, and teleconferencing.

METHODS

In 2019, 56 first- and third-year residents participated in a 3-part, 5-week OSCE training them to use telehealth to manage complex primary care. Learners conducted a standardized patient (SP) televisit in session 1, coordinated care via inter-visit e-messaging, and led a simulated interdisciplinary teleconference in session 2. Surveys measured confidence before session 1 (pre), post-session 1 (post-1), and post-session 2 (post-2). SP televisit checklists and investigators' assessment of e-messages evaluated residents' telehealth skills.

RESULTS

Response rates were pre 100%, post-1 95% (53 of 56), and post-2 100%. Post-intervention, more residents were "confident/very confident" in adjusting their camera (33%, 95% CI 20-45 vs 85%, 95% CI 75-95, P < .0001), e-messaging (pre 36%, 95% CI 24-49 vs post-2 80%, 95% CI 70-91, P < .0001), and coordinating interdisciplinary care (pre 35%, 95% CI 22-47 vs post-2 84%, 95% CI 74-94, P < .0001). More residents were "likely/very likely" to use telemedicine in the future (pre 56%, 95% CI 43-69, vs post-2 79%, 95% CI 68-89, P = .001).

CONCLUSIONS

A longitudinal, interdisciplinary telehealth simulation is feasible and can improve residents' confidence in using telemedicine to provide complex patient care.

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.

Completeness and quality of text paging for subspecialty consult requests

It is unclear whether previously developed frameworks for effective consultation apply to requests initiated by alphanumeric text page. We assessed a random sample of 210 text paged consult requests for communication of previously described 'essential elements' for effective consultation: reason for consult, level of urgency and requester contact information. Overall page quality was evaluated on a 5-point Likert scale. Over 90% of text paged consult requests included contact information and reason for consult; 14% indicated level of urgency. In ordinal logistic regression, reason for consult was most strongly associated with quality (OR 22.4; 95% CI 8.1 to 61.7), followed by callback number (OR 6.2; 95% CI 0.8 to 49.5), caller's name (OR 5.0; 95% CI 1.9 to 13.1) and level of urgency (OR 3.3; 95% CI 1.6 to 6.7). Results suggest that text paged consult requests often include most informational elements, and that urgency, often missing, may not be as 'essential' for text pages as it was once thought to be.

Calling Consults: A Workshop to Teach Trainees Using Both Didactic and Small Group-based Learning

Background: Safe patient care includes effective communication. The Accreditation Council for Graduate Medical Education common program requirements include core requirements for trainees to act in a consultative manner and communicate effectively. However, trainees do not commonly receive formal education on this topic. Objective: We created a 1-hour workshop to teach residents and fellows how to effectively call consults, including how to formulate a cogent and comprehensive consult question. Methods: The workshop, delivered over a 1-hour noon conference, included a didactic portion and interactive small-group case-based learning. We used pre- and postworkshop surveys to assess learners' prior training, knowledge, and comfort levels in calling consults. Subspecialists answered a separate survey about the quality of consults received from trainees before and 30 days after the workshop. Results: Seventy-three trainees attended the workshop (41.2% of total trainees invited). After the workshop, the percentage of learners who identified as very or somewhat comfortable with calling consults increased from 82% to 91%. Before the workshop, 87% of trainees could identify key elements in a consult, which increased to 100% after the workshop. There was not a statistically significant improvement in subspecialists' ratings of the overall quality of consults they received 30 days after the workshop. Conclusion: Training learners on the key components and etiquette of calling consults is crucial for the development of effective communication among providers. This training is generally lacking from undergraduate medical education; thus, it is important to provide education in calling consults during residency and fellowship.

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.

Measuring the quality of inpatient specialist consultation in the intensive care unit: Nursing and family experiences of communication

Rationale

Critically ill patients in the intensive care unit (ICU) often require the care of specialist physicians for clinical or procedural expertise. The current state of communication between specialist physicians and families and nurses has not been explored.

Objectives

To document the receipt of communication by nurses and family members regarding consultations performed on their patient or loved one, and to quantify how this impacts their overall perceptions of the quality of specialty care.

Methods

Prospective survey of 60 adult family members and 90 nurses of 189 ICU patients who received a specialist consultation between March and October of 2015 in a single academic medical center in the United States. Surveys measured the prevalence of direct communication—defined as communication conducted in person, via telephone, or via text-page in which the specialist team gathered information about the patient from the nurse/family member and/or shared recommendations for care—and perceived quality of care.

Results

In about two-thirds of family surveys (40/60) and one-half of nurse surveys (75/160), respondents had no direct communication with the specialist team that performed the consultation. Compared to nurses who had no direct communication with the specialists, those who did were 1.5 times more likely to rate the consultation as “excellent” (RR 1.48, 95% CI 1.2–1.8, p<0.001). Nearly 40% (22/60) of families knew so little about the consultation that they felt incapable of evaluating it.

Conclusions

Most ICU families and nurses have no interaction with specialist providers. Nurses’ frequent exclusion from conversations about specialty care may pose safety risks and increase the likelihood of mixed messages for patients and families, most of whom desire some interaction with specialists. Future research is needed to identify effective mechanisms for information sharing that keep nurses and families aware of consultation requests, delivery, and outcomes without increasing the risk of mixed messages.

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.

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.

A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication

BACKGROUND

Patient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient-physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction.

OBJECTIVE

To determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers.

DESIGN

Internal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective pre-post comparisons.

PARTICIPANTS

Twenty-two internal medicine residents in their second or third postgraduate year.

INTERVENTION

An educational dinner describing the format and potential benefits of using the CPI.

MAIN MEASURES

Retrospective pre-post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians.

KEY RESULTS

All night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups.

CONCLUSIONS

Resident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician-physician communication. These results suggest that the method should be taught and implemented more frequently.

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.

Pediatric Boot Camp Series: Obtaining a Consult, Discussing Difficult News

INTRODUCTION

Transitioning from medical student to intern requires individuals to possess medical knowledge, clinical skills, and the ability to communicate with a wide variety of health care professional as well as patients and their families. New doctors may be expected to function within the health care team without having received explicit instruction in communication previously. The materials associated with this publication are intended to be used as resources for small-group education of graduating medical students entering into pediatric, family medicine, or emergency medicine residencies.

METHODS

Four pediatric cases serve as the focus points for discussion and role-play around calling consultants and discussing difficult news with families and patients. Brief didactics and detailed facilitator notes help prime learning and guide discussion. The included facilitator notes and slide sets are part of the comprehensive materials necessary to implement this 4-hour course at your own institution.

RESULTS

This curriculum has been used since 2012 with graduating medical students entering into pediatric, family medicine, and emergency medicine residencies at two institutions within the United States. Feedback has been overwhelmingly positive, and students have reported increased confidence in their ability to communicate with families and other health care providers.

DISCUSSION

This publication is the second part of a two-part curriculum but may be used independently of the first part. Although the cases are based on pediatrics, the content regarding communication is universal to many medical specialties.

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

OBJECTIVES

The subspecialty consultation represents a potentially powerful opportunity for resident learning, but barriers may limit the educational exchanges between fellows (subspecialty registrars) and residents (house officers). We conducted a focus group study of internal medicine (IM) residents and subspecialty fellows to determine barriers against and factors facilitating resident-fellow teaching interactions on the wards, and to identify opportunities for maximising teaching and learning.

METHODS

We conducted four focus groups of IM residents (n = 18) and IM subspecialty fellows (n = 16) at two academic medical centres in the USA during February and March 2013. Participants represented trainees in all 3 years of residency training and seven IM subspecialties. Four investigators analysed the transcripts using a structured qualitative framework approach, which was informed by literature on consultation and the theoretical framework of activity theory.

RESULTS

We identified two domains of barriers and facilitating factors: personal and systems-based. Sub-themes in the personal domain included fellows' perceived resistance to consultations, residents' willingness to engage in teaching interactions, and perceptions and expectations. Sub-themes in the systems-based domain included the process of requesting the consult, the quality of the consult request, primary team structure, familiarity between residents and fellows, workload, work experience, culture of subspecialty divisions, and fellows' teaching skills. These barriers differentially affected the two stages of the consult identified in the focus groups (initial interaction and follow-up interaction).

CONCLUSIONS

Residents and fellows want to engage in positive teaching interactions in the context of the clinical consult; however, multiple barriers influence both parties in the hospital environment. Many of these barriers are amenable to change. Interventions aimed at reducing barriers to teaching in the setting of consultation hold promise for improving teaching and learning on the wards.