What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up

Impact of an automated patient outcome feedback system on emergency medicine resident patient follow-up: An interrupted time series analysis

Objectives

Emergency medicine (EM) residents desire, but often lack, reliable feedback of patient outcomes following handoffs to other providers. This gap is a substantial barrier to calibrating their diagnostic decision making and learning. To address this educational priority, we developed and evaluated the Post-Handoff Reports of Outcomes (PHAROS) system-an automated system within our electronic health record (EHR) to deliver provider-specific patient outcome feedback.

Methods

PHAROS includes: (1) individualized lists of patients seen and brief summaries of each case, (2) flags for important posthandoff events, and (3) links to charts to facilitate review. Starting June 2020, we coupled PHAROS with a resident educational session and individualized emails every 2 weeks outlining patients seen, number of posthandoff events, and instructions on how to access the PHAROS system.

Results

From July 2017 through April 2022, we measured the proportion of handoffs followed by reaccessing patients' charts between 2 and 14 days posthandoff-a proxy for following up on the patient's outcomes. We performed an interrupted time series analysis on this outcome to determine if PHAROS was associated with a significant change in the trend of our outcome over time. Our secondary outcome was the number of times PHAROS was viewed each month. Our primary outcome had a significant increase in the slope over time (+0.13%/month, p = 0.03) after the introduction of the personalized reports and a nonsignificant change (-1.6%, p = 0.07) at the time of the intervention. The median (IQR) number of views of PHAROS per month was 33.2 (23.75-38.75).

Conclusions

The PHAROS system was associated with a significant increase in the rate of posthandoff chart reaccess among EM residents over time. The PHAROS project demonstrated the feasibility of harnessing the capabilities of the EHR to create an automated system to support EM trainee feedback of patient outcomes-a key component of diagnostic calibration and learning.

A patient follow-up intervention to improve medical decision making at an internal medicine residency program

OBJECTIVES

Practice-based learning and improvement (PBLI) is an ACGME (Accreditation Council for Graduate Medical Education) core competency. Learning and reflecting on patients through follow-up is one method to help achieve this competency. We therefore designed a study evaluating a structured patient follow-up intervention for senior internal medicine (IM) residents at the University of Colorado Hospital (UCH).

METHODS

Trainees completed structured reflections after performing chart review of prior patients during protected educational time. Two-month follow-up surveys evaluated the exercise's potential influence on clinical and reflective practices.

RESULTS

Forty out of 108 (37 %) eligible residents participated in the exercise. Despite 62.5 % of participants lacking specific questions about patient outcomes before chart review, 81.2 % found the exercise at least moderately helpful. 48.4 % of participants believed that the review would change their practice, and 60.9 % felt it reinforced their existing clinical practices. In our qualitative data, residents learned lessons related to challenging clinical decisions, improving transitions of care, the significance of early goals of care conversations, and diagnostic errors/strategies.

CONCLUSIONS

Our results indicate that IM residents found a structured patient follow-up intervention educational, even when they lacked specific patient outcomes questions. Our results underscore the importance of structured self-reflection in the continuous learning process of trainees and suggest the benefit of dedicated educational time for this process.

Learning from the early careers of master clinicians

BACKGROUND

Master clinicians are recognized as multidimensional experts in clinical medicine. Studying their formative clinical activities could generate insights to guide medical trainees and early career clinicians.

OBJECTIVES

To investigate which early career activities were adopted more commonly by master clinicians than their matched peers and to characterize master clinicians' early career activities across institutions and specialties.

SUBJECTS AND METHODS

We surveyed master clinicians at seven medical centres about their early career activities. For master clinicians in the Department of Medicine (DOM), we also surveyed matched internist peers.

RESULTS

Of 150 master clinician respondents, 65% were internists (DOM); 35% practiced in other specialties. Compared to their internist peers, there was a trend toward internist master clinicians reading more about their patients' conditions (6.0 vs. 4.8 h per week), reading more case reports (4.0 vs. 2.1 per month), engaging in more frequent teaching duties and devoting less time to research.

CONCLUSIONS

The early career activities identified in this study can be adopted by clinicians pursuing clinical excellence and promoted by training programs that seek to foster life-long learning.

How to Keep Training-After Residency Training

Lifelong learning in medicine is an important skill and ethical obligation, but many residents do not feel prepared to be effective self-directed learners when training ends. The learning sciences offer evidence to guide self-directed learning, but these insights have not been integrated into a practical and actionable plan for residents to improve their clinical knowledge and reasoning. We encourage residents to establish a self-directed learning plan, just as an athlete employs a training plan in the pursuit of excellence. We highlight four evidence-based learning principles (spaced practice, mixed practice, retrieval practice, and feedback) and four training strategies comprising a weekly training plan: case tracking, simulated cases, quizzing, and new evidence integration. We provide tips for residents to implement and refine their approach and discuss how residency programs can foster these routines and habits. By optimizing their scarce self-directed learning time with a training plan, residents may enhance patient care and their career satisfaction through their pursuit of clinical mastery.

Resident perspectives on the value of interdisciplinary conference calls for geriatric patients

BACKGROUND

There are limited competency-based educational curricula for transitions of care education (TOC) for internal medicine (IM) residency programs. The University of Colorado implemented a virtual interdisciplinary conference call, TEAM (Transitions Expectation and Management), between providers on the inpatient Acute Care of the Elder (ACE) unit and the outpatient Seniors Clinic at the University of Colorado Hospital. Residents rotating on the ACE unit participated in weekly conferences discussing Seniors Clinic patients recently discharged, or currently hospitalized, to address clinical concerns pertaining to TOC. Our goals were to understand resident perceptions of the educational value of these conferences, and to determine if these experiences changed attitudes or practice related to care transitions.

METHODS

We performed an Institutional Review Board-approved qualitative study of IM housestaff who rotated on the ACE unit during 2018-2019. Semi-structured interviews were conducted to understand perceptions of the value of TEAM calls for residents' own practice and the impact on patient care. Data was analyzed inductively, guided by thematic analysis.

RESULTS

Of the 32 IM residents and interns who rotated on ACE and were invited to participate, 11 agreed to an interview. Three key themes emerged from interviews that highlighted residents' experiences identifying and navigating some of their educational 'blind spots:' 1) Awareness of patient social complexities, 2) Bridging gaps in communication across healthcare settings, 3) Recognizing the value of other disciplines during transitions.

CONCLUSIONS

This study highlights learner perspectives of the benefit of interdisciplinary conference calls between inpatient and outpatient providers to enhance transitions of care, which provide meaningful feedback and serve as a vehicle for residents to recognize the impact of their care decisions in the broader spectrum of patients' experience during hospital discharge. Educators can maximize the value of these experiences by promoting reflective debriefs with residents and bringing to light previously unrecognized knowledge gaps around hospital discharge.

Barriers to Learning Clinical Reasoning: a Qualitative Study of Medicine Clerkship Students

Clinical reasoning is crucial to good patient care, but both learning and applying clinical reasoning skills in the context of a complex working environment can be challenging. We sought to understand the perceived barriers to learning clinical reasoning, as experienced by internal medicine clerkship students at our institution. We invited internal medicine clerkship students to participate in focus groups to discuss their experiences with and barriers to learning clinical reasoning. A survey was administered to gather additional responses. Responses were reviewed, coded, and synthesized to identify key themes. Twenty-nine medicine clerkship students (male = 14, female = 15) participated in six 60-minute focus groups, and 121 (61% response rate) students responded to the barriers to clinical reasoning survey from March 2018 to May 2019. We identified three themes (clerkship acclimation, data access, and practice optimization) and ten subthemes as aspects of the clerkship environment that impacted students' ability to develop clinical reasoning skills. Students identified barriers to learning clinical reasoning during the internal medicine clerkship. The themes "clerkship acclimation" and "data access" were identified as prerequisites to clinical reasoning while the theme "practice optimization" described key components of the deliberate practice of clinical reasoning. Educators and health systems may improve the development of clinical reasoning by recognizing and overcoming these barriers within clinical learning environments.

Decisions in the Dark: An Educational Intervention to Promote Reflection and Feedback on Night Float Rotations

BACKGROUND

Night float rotations, where residents admit patients to the hospital, are opportunities for practice-based learning. However, night float residents receive little feedback on their diagnostic and management reasoning, which limits learning.

AIM

Improve night float residents' practice-based learning skills through feedback solicitation and chart review with guided reflection.

SETTING/PARTICIPANTS

Second- and third-year internal medicine residents on a 1-month night float rotation between January and August 2017.

PROGRAM DESCRIPTION

Residents performed chart review of a subset of patients they admitted during a night float rotation and completed reflection worksheets detailing patients' clinical courses. Residents solicited feedback regarding their initial management from day team attending physicians and senior residents.

PROGRAM EVALUATION

Sixty-eight of 82 (83%) eligible residents participated in this intervention. We evaluated 248 reflection worksheets using content analysis. Major themes that emerged from chart review included residents' identification of future clinical practice changes, evolution of differential diagnoses, recognition of clinical reasoning gaps, and evaluation of resident-provider interactions.

DISCUSSION

Structured reflection and feedback during night float rotations is an opportunity to improve practice-based learning through lessons on disease progression, clinical reasoning, and communication.

Exploring current physicians' failure to communicate clinical feedback back to transferring physicians after transitions of patient care responsibility: A mixed methods study

INTRODUCTION

After patient care transitions occur, communication from the current physician back to the transferring physician may be an important source of clinical feedback for learning from outcomes of previous reasoning processes. Factors associated with this communication are not well understood. This study clarifies how often, and for what reasons, current physicians do or do not communicate back to transferring physicians about transitioned patients.

METHODS

In 2018, 38 physicians at two academic teaching hospitals were interviewed about communication decisions regarding 618 transitioned patients. Researchers recorded quantitative and qualitative data in field notes, then coded communication rationales using directed content analysis. Descriptive statistics and mixed effects logistic regression analyses identified communication patterns and examined associations with communication for three conditions: When current physicians 1) changed transferring physicians' clinical decisions, 2) perceived transferring physicians' clinical uncertainty, and 3) perceived transferring physicians' request for communication.

RESULTS

Communication occurred regarding 17% of transitioned patients. Transferring physicians initiated communication in 55% of these cases. Communication did not occur when current physicians 1) changed transferring physicians' clinical decisions (119 patients), 2) perceived transferring physicians' uncertainty (97 patients), and 3) perceived transferring physicians' request for communication (12 patients). Rationales for no communication included case contextual, structural, interpersonal, and cultural factors. Perceived uncertainty and request for communication were positively associated with communication (p < 0.001) while a changed clinical decision was not.

DISCUSSION

Current physicians communicate infrequently with transferring physicians after assuming patient care responsibilities. Structural and interpersonal barriers to communication may be amenable to change. Clarity about transferring physicians' uncertainty and desire for communication back may improve clinical feedback communication.

Trainee and Program Director Perspectives on Meaningful Patient Attribution and Clinical Outcomes Data

BACKGROUND

The Accreditation Council for Graduate Medical Education specifies that trainees must receive clinical outcomes and quality benchmark data at specific levels related to institutional patient populations. Program directors (PDs) are challenged to identify meaningful data and provide them in formats acceptable to trainees.

OBJECTIVE

We sought to understand what types of patients, data/metrics, and data delivery systems trainees and PDs prefer for supplying trainees with clinical outcomes data.

METHODS

Trainees (n = 21) and PDs (n = 12) from multiple specialties participated in focus groups during academic year 2017-2018. They described key themes for providing clinical outcomes data to trainees.

RESULTS

Trainees and PDs differed in how they identified patients for clinical outcomes data for trainees. Trainees were interested in encounters where they felt a sense of responsibility or had autonomy/independent decision-making opportunities, continuity, or learned something new; PDs used broader criteria including all patients cared for by their trainees. Both groups thought trainees should be given trainee-level metrics and consistently highlighted the importance of comparison to peers and/or benchmarks. Both groups found value in "push" and "pull" data systems, although trainees wanted both, while PDs wanted one or the other. Both groups agreed that trainees should review data with specific faculty. Trainees expressed concern about being judged based on their patients' clinical outcomes.

CONCLUSIONS

Trainee and PD perspectives on which patients they would like outcomes data for differed, but they overlapped for types of metrics, formats, and review processes for the data.

Interprofessional 30-day readmission review novel curriculum

Planning and coordination among health-care professionals decrease readmission rates, yet workers have few opportunities to learn interprofessionally to improve transitions of care. An interprofessional readmission review curriculum engaged medical residents, pharmacy residents, nurse practitioner students, early-career nurses, and social work students in a critical analysis of readmissions. Learners (N = 98) participated in a 2 h, collaborative learning session to review health records from a patient readmitted within 30 days of discharge and determine plausible root causes for readmissions. A 5-item post-session survey completed by 83 (85%) evaluated knowledge and perceived competencies in transitions of care before and after participation. Significant improvements (p < .001) occurred in ratings for all five items. Two open-ended questions captured learners' perceptions of understanding and appreciating the roles of other disciplines in the discharge process and importance of interprofessional communication. Several themes emerged including understanding gaps in the discharge process, improving interprofessional collaboration and communication, and paying more attention to discharge documentation. This innovative program helped build essential skills to ensure safe discharges by introducing learners to interprofessional perspectives in analyzing root causes for readmissions, strategies to improve discharge planning, and the value of team-based care.

"Closing the loop": a mixed-methods study about resident learning from outcome feedback after patient handoffs

Background Learning patient outcomes is recognized as crucial for ongoing refinement of clinical decision-making, but is often difficult in fragmented care with frequent handoffs. Data on resident habits of seeking outcome feedback after handoffs are lacking. Methods We performed a mixed-methods study including (1) an analysis of chart re-access rates after handoffs performed using access logs of the electronic health record (EHR); and (2) a web-based survey sent to internal medicine (IM) and emergency medicine (EM) residents about their habits of and barriers to learning the outcomes of patients after they have handed them off to other teams. Results Residents on ward rotations were often able to re-access charts of patients after handoffs, but those on EM or night admitting rotations did so <5% of the time. Among residents surveyed, only a minority stated that they frequently find out the outcomes of patients they have handed off, although learning outcomes was important to both their education and job satisfaction. Most were not satisfied with current systems of learning outcomes of patients after handoffs, citing too little time and lack of reliable patient tracking systems as the main barriers. Conclusions Despite perceived importance of learning outcomes after handoffs, residents cite difficulty with obtaining such information. Systematically providing feedback on patient outcomes would meet a recognized need among physicians in training.