The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour & improve safety

BACKGROUND

Prescribing alerts of an electronic health record are meant to be protective, but often are disruptive to providers. Our goal was to assess the effectiveness of interruptive medication-prescriber alerts in changing prescriber behaviour and improving patient outcomes in ambulatory care settings via computerised provider order entry (CPOE) systems.

METHODS

A standardised search strategy was developed and applied to the following key bibliographical databases: PubMed, Embase, CINAHL and The Cochrane Library. Non-comparison studies and studies on non-interrupted alerts were eliminated. We developed a standardised data collection form and abstracted data that included setting, study design, category of intervention alert and outcomes measured. The search was completed in August 2018 and repeated in November of 2019 and of 2020 to identify any new publications during the time lapse.

RESULTS

Ultimately, nine comparison studies of triggered alerts were identified. Each studied at least one outcome measure illustrating how the alert affected prescriber decision-making. Provider behaviour was influenced in the majority, with most noting a positive change. Alerts decreased pharmaceutical costs, moved medications toward preferred medications tiers and steered treatments toward evidence-based choices. They also decreased prescribing errors. Clinician feedback, rarely solicited, expressed frustration with alerts creating a time delay.

CONCLUSION

The current evidence shows a clear indication that many categories of alerts are effective in changing prescriber behaviour. However, it is unclear whether these behavioural changes lead to improved patient outcomes. Despite the rapid transition to CPOE use for patient care, there are few rigorous studies of triggered alerts and how workflow interruptions impact patient outcomes and provider acceptance.

Begin with the End in Mind: Designing and Implementing an Effective System for Evaluation and Feedback of Learners in Regional Medical Campus Residency Settings

Developing an evaluation system within a medical education program can be daunting and confusing.  The authors present a step by step approach, incorporating education theory, recent trends, and the many facets required by accreditation organizations.

A Conversation About the Role of Humiliation in Teaching: The Ugly, the Bad, and the Good

In this Invited Commentary, the authors identify the ugly, the bad, and the good in teaching in medical education, based on their experiences as medical students and then educators. They reflect on the mistreatment they endured during medical school and its impact on their education and their careers as educators. They also highlight those exemplars from their training who role modeled the type of physician and educator they want to be. The authors conclude by describing the elements of learner-centered education that they practice, which may be helpful for others to consider, and call on their fellow educators to end the practice of humiliating learners by moving away from a controlled-motivation model toward an autonomy-supportive approach to education.

From Probation to Accreditation: Successful Change Management

Background:  In 2015 our residency program located within a regional medical campus was placed on probation.  Five of the 13 citations were related to the residents’ clinic experience.  The resident clinic was encased within a medical culture of chronic opiate prescription management that did not provide a sufficient or balanced ambulatory education for internal medicine residents. Objective:  This paper describes our experience of moving from a residency program within a regional medical campus on probation to full accreditation status over a 19-month time period. Methods: We used a project management approach with a strong coordinating council designed to empower leaders to effect change in the residency program, and in particular, the residency clinic.  Results: We were able to create and enact a plan that extricated the residency’s ambulatory clinic from managing a panel of ~700 patients requiring chronic monthly opiate prescriptions. The patients were referred to community pain management providers for these prescriptions. We established a policy of providing no chronic opiate prescriptions in the residency clinic. Residency ACGME surveys from 2015 through 2017 demonstrated improved resident satisfaction. CG-CAHPS scores demonstrated a temporary decrease in patient satisfaction scores returning to previous baseline after a year. Conclusion: We employed a project management approach to 1) get our program off probation, and 2) change the focus of our residency’s ambulatory practice and re-establish its educational mission.

Teaming up to take down costs

By linking specialty-specific clinical teams with supply chain experts, Saint Luke's Health System established cost-containment strategies that align with clinical pathways and create new leverage with vendors. Since the initiative launched in January 2013, Saint Luke's has reduced medical supply costs by more than $6 million. In several instances, physicians have led the way in formulating cost-cutting ideas that exceeded the expectations of supply chain administrators.

Transport of Residual Nitrogen and Carbon through Intact Soil Cores Amended with Stockpiled Feedlot Manure with Wood-Chip or Straw Bedding

The environmental impact of using wood chips instead of straw bedding with feedlot manure on transport and leaching potential from feedlot manure is unknown. Our main objective was to determine if transport of total N, total organic N, NO-N, and nonpurgeable organic C (NPOC) to subsurface soil was lower for soils amended with feedlot manure if combined with wood chips compared with straw. A secondary objective was to compare transport of N and NPOC with organic amendments versus inorganic fertilizer. Stockpiled feedlot manure (SM) with wood chip (SM-WD) or barley straw (SM-ST) bedding at 39 Mg (dry wt.) ha, and inorganic fertilizer (IN) at 100 kg N ha, was applied annually for 13 yr to a clay loam soil in a replicated field experiment in southern Alberta, Canada. Intact soil cores were taken in fall 2011 (0-30 cm depth) from the three treatments, and the residual N and NPOC were eluted from the soil cores. Total N, total organic N, and NPOC were determined on filtered (1.0 μm) effluent samples that are primarily dissolved fraction but may contain some small particulate N and C. Peak concentrations, flow-weighted mean concentrations, and mass loss of total N, total organic N, NO-N, and NPOC were significantly ( ≤ 0.05) lower by 35 to 86% for SM-WD compared with SM-ST. Mean recoveries were also significantly lower for SM-WD than SM-ST by 0.07 to 8% (absolute difference). The transport behavior was similar for SM-WD and IN treatment, but solute transport was greater for SM-ST than for IN. Application of stockpiled feedlot manure with wood chips instead of straw bedding may be a beneficial management practice to reduce transport and leaching potential of N fractions and NPOC.

Ambulatory office organization for internal medicine resident medical education

PURPOSE

Residents will most effectively learn about ambulatory, systems-based practice by working in highly functional ambulatory practices; however, systems experiences in ambulatory training are thought to be highly variable. The authors sought to determine the prevalence of functional-practice characteristics at clinics where residents learn.

METHOD

In 2007, the authors conducted a national survey of medical directors of resident continuity clinics using a comprehensive, Web-based instrument that included both a residency clinic assessment and a practice system assessment (PSA). The authors designed the PSA to estimate the Physician Practice Connections (PPC) score, indicating the readiness of a practice to function as a patient-centered medical home (PCMH).

RESULTS

Of 356 clinic directors or physician representatives responding to an initial inquiry, 221 completed the survey (62%)--representing 185 programs (49% of accredited programs). The majority of clinics were hospital based (139/220; 63%) or hospital supported (41/220; 19%) and were located in urban settings (151/217; 70%). Estimated payer mix categories included Medicare or managed Medicare (169; 29%), Medicaid or managed Medicaid (161; 34%), and self-pay (156; 25%). The mean estimated PPC score was 53 points (of 100; SD = 17.6). Suburban and rural clinics, Veterans Affairs' clinics, federally qualified health centers, and clinics with a higher proportion of patients with commercial insurance or managed Medicare earned higher scores.

CONCLUSIONS

A substantial portion of residency clinics have elements needed for PCMH recognition. However, clinics struggled with connecting these elements with coordination-of-care processes, suggesting areas for improvement to support better functioning of ambulatory training practices.

Prevalence and functionality of electronic health records in internal medicine continuity clinics

PURPOSE

Health information technology (HIT), particularly electronic health records (EHRs), will become universal in ambulatory practices, but the current roles and functions that HIT and EHRs play in the ambulatory clinic settings of internal medicine (IM) residents are unknown.

METHOD

The authors conducted a Web-based survey from July 2007 to January 2008 to ascertain HIT prevalence and functionality. Respondents were directors of one or more ambulatory clinics where IM residents completed any required outpatient training, as identified by directors of accredited U.S. IM residencies.

RESULTS

The authors identified 356 clinic directors from 264 accredited U.S. programs (70%); 221 directors (62%) completed the survey, representing 185 accredited programs (49%). According to responding directors, residents in 121 of 216 clinics (56%) had access to EHRs, residents in 147 of 219 clinics (67%) used some type of electronic data system (EDS) to manage patient information, and residents in 62 clinics (28% of 219 responding) used an EDS to generate lists of patients needing follow-up care. Compared with smaller IM training programs, programs with > or =50 trainees were more likely to have an EDS (67% versus 53%, P = .037), electronic prescription writer (57% versus 42%, P = .026), or EHR (63% versus 45%, P = .007).

CONCLUSIONS

Resident ambulatory clinics seem to have greater adoption of HIT and EHRs than practicing physicians' ambulatory offices. Ample room for improvement exists, however, as electronic systems with suboptimal patient data, limited functionality, and reliance on multiple (paper and electronic) systems all hinder residents' ability to perform important care coordination activities.

Hospitalist involvement in internal medicine residencies

CONTEXT

The ways hospitalists interact with and contribute to internal medicine residencies in the United States have been described locally, but have not been documented on a national level.

OBJECTIVES

To describe the penetration of hospitalists into medicine residency faculty nationally, and document their contributions to teaching activities.

DESIGN, SETTING, AND PARTICIPANTS

Survey of all 386 internal medicine residency directors in the United States in 2005 (272 respondents) and 2007 (236 respondents).

MEASUREMENTS

Number of teaching hospitals utilizing hospitalists, number of programs utilizing hospitalists to teach, hospitalist teaching duties, and number with hospitalist tracks.

RESULTS

In 2005, program directors recalled 54% of teaching hospitals employed hospitalists before and 73% after implementation of work-hour limitations. Of those employing hospitalists, 92% of programs in the Northeast and West used them to teach. Two years later, the Midwest (78%) and South (76%) continued to lag behind in the proportion of teaching hospitalists. Specific teaching activities of hospitalists included: attending on teaching service (92%), conducting rounds (81%), observation of clinical skills (67%), lectures (68%), and morning report (52%). Seven percent of program directors reported other duties of hospitalists, including: supervising procedures, reviewing night float patients, serving as associate program directors, and writing curricula. Eleven percent of training programs had hospitalist tracks.

CONCLUSIONS

As hospitalists have become prevalent and have become efficient clinicians in community and university hospitals, the majority of internal medicine residencies have enlisted them to provide rounds, lectures, and bedside teaching. A small number of residencies are beginning to develop tracks to facilitate this new career option for graduates.

Humor in intern retreats: scrubbing away the blues

Humor in everyday practice has been shown to reduce work stress and increase efficiency. We aimed to study the effect of humor on interns for which we employed humor in one of the intern retreats and later asked the interns to rate the value of each retreat. Pre- and post- retreat mood states were also surveyed. The majority of interns recommended that humorous intern retreats be used in the coming years. A trend towards improvement in depression scores was also noticed.

Demographic and work-life study of chief residents: a survey of the program directors in internal medicine residency programs in the United States

CONTEXT

Chief residents play a crucial role in internal medicine residency programs in administration, academics, team building, and coordination between residents and faculty. The work-life and demographic characteristics of chief residents has not been documented.

OBJECTIVE

To delineate the demographics and day-to-day activities of chief residents.

DESIGN, SETTING, AND PARTICIPANTS

The Survey Committee of the Association of Program Directors in Internal Medicine (APDIM) developed a Web-based questionnaire. A link was sent in November 2006 by e-mail to 381 member programs (98%). Data collection ended in April 2007.

MEASUREMENTS

Data collected include the number of chief residents per residency, the ratio of chief residents per resident, demographics, and information on salary/benefits, training and mentoring, and work life.

RESULTS

The response rate was 62% (N  =  236). There was a mean of 2.5 chief residents per program, and on average there was 1 chief resident for 17.3 residents. Of the chief residents, 40% were women, 38% international medical graduates, and 11% minorities. Community-based programs had a higher percentage of postgraduate year 3 (PGY-3)-level chief residents compared to university-based programs (22% versus 8%; P  =  .02). Mean annual salary was $60 000, and the added value of benefits was $21 000. Chief residents frequently supplement their salaries through moonlighting. The majority of formal training occurs by attending APDIM meetings. Forty-one percent of programs assign academic rank to chief residents.

CONCLUSION

Most programs have at least 2 chief residents and expect them to perform administrative functions, such as organizing conferences. Most programs evaluate chief residents regularly in administration, teaching, and clinical skills.

What predicts residency accreditation cycle length? Results of a national survey

PURPOSE

To determine whether residency program baseline characteristics, program director characteristics, and the date of the most recent Accrediation Council for Graduate Medical Education (ACGME) site visit would affect program accreditation cycle length.

METHOD

A survey asked about cycle length as well as program and program director characteristics. The survey was sent to all 391 accredited internal medicine residency programs registered with the Association of Program Directors in Internal Medicine in March 2005. Bivariate and multivariate regressions were performed to find factors independently associated with cycle length.

RESULTS

The mean cycle length was 3.8 years among respondents (70% response rate). Program characteristics associated with longer cycle length included having a higher three-year American Board of Internal Medicine (ABIM) board pass rate. Program characteristics associated with shorter cycle length included being reviewed by the Residency Review Committee in Internal Medicine (RRC-IM) shortly after the July 2003 ACGME program requirement changes, being a university-based program, and having a large percentage of voluntary teaching faculty. Program director characteristics associated with longer cycle length included time spent in clinic. Other program and program director characteristics had no effect on cycle length.

CONCLUSIONS

Several program and program director characteristics are associated with RRC-IM cycle length. Programs should be wary of the dates of their Residency Review Committee site visits in relation to ACGME programmatic rule changes. The percentage of voluntary faculty at each program, the ABIM board pass rate, and the amount of time the program director spends in clinic also affect a program's cycle length.

What do you do when your loved one is ill? The line between physician and family member

Conventional wisdom and professional ethics generally dictate that physicians should avoid doctoring family members because of potential conflicts of interest. Nevertheless, cross-sectional surveys find that the practice is commonplace. Physicians have unique opportunities to influence their family member's care because they possess knowledge and status within the health care system; however, when physicians participate in the care of family members, they must not lose objectivity and confuse their personal and professional roles. Because health care systems are complicated, medical information is difficult to understand, and medical errors are common, it can be a great relief for families to have someone "on the inside" who is accessible and trustworthy. Yet, the benefits of becoming involved in a loved one's care are accompanied by risks, especially when a physician takes action that a nonphysician would be incapable of performing. Except for convenience, most if not all of the benefits of getting involved can be realized by physician-family members acting as a family member or an advocate rather than as a physician. Rules about what is or what is not appropriate for physician-family members are important but insufficient to guide physicians in every circumstance. Physician-family members can ask themselves, "What could I do in this situation if I did not have a medical degree?" and consider avoiding acts that require a medical license.

The state of evaluation in internal medicine residency

BACKGROUND

There are no nationwide data on the methods residency programs are using to assess trainee competence. The Accreditation Council for Graduate Medical Education (ACGME) has recommended tools that programs can use to evaluate their trainees. It is unknown if programs are adhering to these recommendations.

OBJECTIVE

To describe evaluation methods used by our nation's internal medicine residency programs and assess adherence to ACGME methodological recommendations for evaluation.

DESIGN

Nationwide survey.

PARTICIPANTS

All internal medicine programs registered with the Association of Program Directors of Internal Medicine (APDIM).

MEASUREMENTS

Descriptive statistics of programs and tools used to evaluate competence; compliance with ACGME recommended evaluative methods.

RESULTS

The response rate was 70%. Programs were using an average of 4.2-6.0 tools to evaluate their trainees with heavy reliance on rating forms. Direct observation and practice and data-based tools were used much less frequently. Most programs were using at least 1 of the Accreditation Council for Graduate Medical Education (ACGME)'s "most desirable" methods of evaluation for all 6 measures of trainee competence. These programs had higher support staff to resident ratios than programs using less desirable evaluative methods.

CONCLUSIONS

Residency programs are using a large number and variety of tools for evaluating the competence of their trainees. Most are complying with ACGME recommended methods of evaluation especially if the support staff to resident ratio is high.

Personal growth during internship: a qualitative analysis of interns' responses to key questions

BACKGROUND

During clinical training, house officers frequently encounter intense experiences that may affect their personal growth. The purpose of this study was to explore processes related to personal growth during internship.

DESIGN

Prospective qualitative study conducted over the course of internship.

PARTICIPANTS

Thirty-two postgraduate year (PGY)-1 residents from 9 U.S. internal medicine training programs.

APPROACH

Every 8 weeks, interns responded by e-mail to an open-ended question related to personal growth. Content analysis methods were used to analyze the interns' writings to identify triggers, facilitators, and barriers related to personal growth.

RESULTS

Triggers for personal growth included caring for critically ill or dying patients, receiving feedback, witnessing unprofessional behavior, experiencing personal problems, and dealing with the increased responsibility of internship. Facilitators of personal growth included supportive relationships, reflection, and commitment to core values. Fatigue, lack of personal time, and overwhelming work were barriers to personal growth. The balance between facilitators and barriers may dictate the extent to which personal growth occurs.

CONCLUSIONS

Efforts to support personal growth during residency training include fostering supportive relationships, encouraging reflection, and recognizing interns' core values especially in association with powerful triggers.

Perceived, actual, and desired knowledge regarding Medicare billing and reimbursement. A national needs assessment survey of internal medicine residents

BACKGROUND

Economics and reimbursement have become a daily part of practicing physicians' lives. Yet, few internal medicine (IM) programs have offered formal curricula during residency about practice management or economics.

OBJECTIVE

To determine perceived, desired, and actual knowledge of Medicare billing and reimbursement among residents compared with community-based General Internists.

DESIGN AND PARTICIPANTS

Cross-sectional needs assessment survey of community and university-based second-year IM residents from 4 geographic regions of the United States.

RESULTS

One hundred and thirty-three second-year IM residents completed the questionnaire. Residents rated their level of knowledge about Medicare as a 2.0 (SD=0.9) on a Likert scale (1="very low," 5="very high"). Residents agreed that Medicare reimbursement should be taught in residency with a score of 4.0 (SD=1.1; 1="strongly disagree," 5="strongly agree" SD=1.1). On the knowledge assessment portion of the questionnaire, residents scored significantly lower than a group of general IM physicians who completed the same questions (percent correct=41.8% vs 59.0%, P<.001). Residents' scores correlated with their self-assessed level of knowledge (P=.007).

CONCLUSIONS

Our study demonstrates that second year IM residents feel they have a low level of knowledge regarding outpatient Medicare billing, and have a lower test score than practicing Internists to back up their feelings. The residents also strongly agree that they do not receive enough education about Medicare reimbursement, and believe it should be a requirement in residency training.

A time to be promoted. The Prospective Study of Promotion in Academia (Prospective Study of Promotion in Academia)

OBJECTIVE

The study's objectives were to determine (1) the rate at which department of medicine faculty in the United States are promoted, (2) if clinician-educators (CEs) are promoted to Associate Professor at the same rate as clinician-investigators (CIs), and (3) the variables that predict promotion.

METHODS

The Prospective Study of Promotion in Academia was a part-retrospective, part-prospective (from 2000 to 2003) cohort study. Six-hundred and four Internal Medicine junior faculty across the United States who had been registered as new appointees with the Association of American Medical Colleges in 1995 were invited to participate. Twenty-one percent of these had already left their institution when the study began. One hundred and eighty-three Internal Medicine faculty from 87 institutions in 35 states enrolled. The main outcome measure was the time from appointment as Assistant Professor to promotion to Associate Professor.

RESULTS

Follow-up was complete for all 183 faculty. Among the faculty that achieved promotion, the estimated median time to promotion was 6.0 years (95% Conf. Int.=5.8 to 6.2). The unadjusted sixth-year promotion rate for CEs was 16%, while for CIs it was 26% (P=.002). Independent negative predictors of promotion included low amount of research time (Hazard Ratio [HR] =0.3, 95% Conf. Int.=0.2 to 0.5), having a manuscript review service (HR=0.4, 95% Conf. Int.=0.2 to 0.7), never meeting with Chairman/Chief about promotion (HR=0.4, 95% Conf. Int.=0.2 to 0.7), low job satisfaction (HR=0.5, 95% Conf. Int.=0.3 to 0.9), and working in the Northeast (HR=0.6, 95% Conf. Int.=0.4 to 1.1). Positive predictors included making between 130 dollars and 149,000 dollars per year (HR=1.9, 95% Conf. Int.=1.1 to 3.4), working more than 60 h/wk (HR=1.9, 95% Conf. Int.=1.1 to 3.0), having a career mentor available (HR=1.8, 95% Conf. Int.=1.1 to 2.9), and having access to a grant office (HR=1.6, 95% Conf. Int.=1.0 to 2.6).

CONCLUSION

CEs and CIs appear to be promoted at different rates. The characteristics that are independently associated with earlier promotion may be helpful for institutions and individual faculty that are committed to achieving promotion efficiently.

Motivating factors for academic physicians within departments of medicine

OBJECTIVE

To understand what motivates academic physicians at a time when physician dissatisfaction is prevalent.

SUBJECTS AND METHODS

Of a cohort of 480 physician faculty members (identified from the Association of American Medical Colleges faculty roster) hired at the assistant professor level, 183 were monitored prospectively for a characterization of their success in achieving promotion. In mid-2001, follow-up data were collected about the factors that physicians described as motivating in their work. We conducted this study to understand the differences in motivators between clinician-educators and cliniclan-investigators and between male and female physicians, as well as to validate a previously used instrument developed to assess motivation and occupational values.

RESULTS

Of 183 physicians monitored, 144 (79%) responded to an interim follow-up questionnaire. Factor analysis revealed that physicians' occupational motivators could be grouped statistically into 3 factors: self-expression, helping others, and extrinsic rewards. Compared with clinician-educators, clinician-investigators were more motivated in their current work by having the ability to express themselves (composite factor score, 4.30 vs 3.84; P<.001). Clinician-investigators also rated 4 of the 6 items within the factor of self-expression as being significantly stronger motivators for them than did the clinician-educators. Compared with male physicians, female physicians Indicated they were more motivated by helping others (composite factor score, 4.18 vs 3.89; P=.03).

CONCLUSIONS

Factors that motivate physicians appear to be different for clinician-investigators and clinician-educators as well as for male and female physicians. Understanding the inspiration for physicians may help medical leadership to better motivate and relate to their physician workforce.

Comparing practice differences of residency graduates: implications for curricular change

OBJECTIVE

To document and assess differences in the practice experiences and practice patterns of graduates from two similar sized but regionally separated community-based internal medicine residency programs.

RESULTS

Sixty percent responded to the survey. Responses from graduates practicing general internal medicine were used in the analyses (Wichita n = 20; Baystate n = 23). Only graduates from Wichita were in solo practice (15%). Baystate graduates had a significantly higher percentage of HMO patients (32% vs. 17%, p < .05). A higher percentage of Kansas respondents worked in a community with a population of less than 50,000 (55% vs. 26%, p = .052). Of 28 components of a residency curriculum, 7 were considered significantly more important to daily practice by Kansas respondents than by Baystate respondents: Critical Care, Dermatology, Gastroenterology, Nephrology, Neurology, Occupational Medicine, and Rheumatology. Kansas respondents performed on average significantly more procedures than Massachusetts respondents in the last year in 6 of 16 procedures: bone marrow biopsy, exercise stress tests, flexible sigmoidoscopy, liquid nitrogen, skin biopsy, and thoracentesis. The procedures of skin biopsy, stress testing, and the curricula of dermatology, nephrology, neurology and rheumatology remained significantly different when controlled for the size of the community population (<50,000). Wichita graduates scored higher on the practice intensity measure than Baystate graduates.

CONCLUSIONS

We have documented differences in the importance of particular curricula, procedures, and practice intensity likely related to the community population in which residency graduates practice. Understanding the needs of graduates and incorporating this information into existing rotations or new initiatives is integral to the ongoing development of residency curricula.

Incidence of venous thromboembolic events among nursing home residents

Chronic care facility stay has been shown to be an independent risk factor for venous thromboembolism. Review of the literature, however, reveals a paucity of data addressing the issue of venous thromboembolism in nursing home residents. The purpose of this study was to determine the incidence of venous thromboembolic events among nursing home residents. A retrospective cohort study was derived from data compiled in the State of Kansas Minimum Data Set (MDS) for nursing home residents from July 1, 1997 to July 1, 1998. A total of 18,661 residents (median age, 85 years, 74% female, 95% white) satisfied the study criteria. The outcome measures of the primary endpoint-development of a venous thromboembolic event (VTE)-were obtained from the MDS quarterly health assessments and the Medicare ICD-9 codes. We determined the incidence of VTE among nursing home residents as 1.30 events per 100 person-years of observation.

Promotion criteria for clinician-educators

OBJECTIVE

Department of medicine chairs have a critical role in the promotion of clinician-educators. Our primary objective was to determine how chairs viewed: 1) the importance of specific areas of clinician-educator performance in promotion decisions; and 2) the importance and quality of information on available measures of performance. A secondary objective was to compare the views of department chairs with those of promotion and tenure committee chairs.

METHODS

In October 1997, a questionnaire was mailed to all department chairs in the United States and Canada asking them to rate the importance of 11 areas of clinician-educators' performance in evaluating them for promotion. We also asked them to rate 36 measures of performance. We compared their responses to a similar 1996 survey administered to promotion committee chairs.

RESULTS

One hundred fourteen of 139 department chairs (82%) responded to the survey. When considering a clinician-educator for promotion, department chairs view teaching skills and clinical skills as the most important areas of performance, as did the promotion committee chairs. Of the measures used to evaluate teaching performance, teaching awards were considered most important and rated as a high-quality measure. When evaluating a clinician-educator's clinical skills, peer and trainee evaluation were considered as the most important measures of performance, but these were rated low in quality. Patient satisfaction and objective outcome measures also were viewed as important measures that needed improvement. Promotion committee chairs placed more emphasis on productivity in publications and external grant support when compared to department chairs.

CONCLUSION

It is reassuring that both department chairs and promotion committee chairs value teaching skills and clinical skills as the most important areas of a clinician-educator's performance when evaluating for promotion. However, differences in opinion regarding the importance of several performance measures and the need for improved quality measures may represent barriers to the timely promotion of clinician-educators.

Looking forward to promotion: characteristics of participants in the Prospective Study of Promotion in Academia

OBJECTIVES

To determine what clinician-educators consider important for promotion, and what support they find helpful and useful for success.

DESIGN

Cross-sectional study.

SETTING

Eighty academic medical centers in the United States.

PARTICIPANTS

One hundred eighty-three participants of the Prospective Study of Promotion in Academia comprising assistant professors in departments of medicine from 80 different medical schools in 35 states.

MEASUREMENTS

Differences between clinician-educators' and clinician-investigators' work activities, promotion preparedness, and faculty support needs.

RESULTS

One hundred seven (58%) of the faculty were clinician-educators (CEs), and 63 (34%) were clinician-investigators (CIs); the remaining 13 fit neither category. Participants had been in their faculty position for 4.7 years. Ninety-eight percent of CIs reported a publication expectation for promotion, and 75% of CEs also reported such an expectation. More CIs had career mentors available than CEs (68% vs 32%, P <.001). Seventy-nine percent of CIs indicated >10% protected scholarly work time, compared to only 35% of CEs (P <.001). Fifty-three percent of CIs as compared to 32% of CEs (P <.01) meet more often than yearly with their chief/chair for performance review, and more CIs have seen written promotion guidelines (72% vs 51%, P <.01). Clinician educators believed out of 11 job performance areas, research, written scholarship, and reputation were the 3 most important factors that would determine the success of their application for promotion. Both CEs and CIs sense that CIs are more likely get promoted (82% vs 79%).

CONCLUSIONS

Clinician educators are less familiar with promotion guidelines, meet less often with superiors for performance review, and have less protected time than CI colleagues. There is dissonance between CEs' beliefs and previously published data from promotion committee chairs in the importance given to specific aspects of job performance.

Rehabilitation for patients with chronic obstructive pulmonary disease: meta-analysis of randomized controlled trials

OBJECTIVE

To develop a meta-analysis to determine the effectiveness of rehabilitation in patients with chronic obstructive pulmonary disease (COPD).

DATA SOURCES

medline, cinhal, and Cochrane Library searches for trials of rehabilitation for COPD patients. Abstracts presented at national meetings and the reference lists of pertinent articles were reviewed.

STUDY SELECTION

Studies were included if: trials were randomized; patients were symptomatic with forced expiratory volume in one second (FEV1) <70% or FEV1 divided by forced vital capacity (FEV1/FVC) <70% predicted; rehabilitation group received at least 4 weeks of rehabilitation; control group received no rehabilitation; and outcome measures included exercise capacity or shortness of breath. We identified 69 trials, of which 20 trials were included in the final analysis.

DATA EXTRACTION

Effect of rehabilitation was calculated as the standardized effect size (ES) using random effects estimation techniques.

RESULTS

The rehabilitation groups of 20 trials (979 patients) did significantly better than control groups on walking test (ES = 0.71; 95% confidence interval [95% CI], 0.43 to 0.99). The rehabilitation groups of 12 trials (723 patients) that used the Chronic Respiratory Disease Questionnaire had less shortness of breath than did the control groups (ES = 0.62; 95% CI, 0.35 to 0.89). Trials that used respiratory muscle training only showed no significant difference between rehabilitation and control groups, whereas trials that used at least lower-extremity training showed that rehabilitation groups did significantly better than control groups on walking test and shortness of breath. Trials that included severe COPD patients showed that rehabilitation groups did significantly better than control groups only when the rehabilitation programs were 6 months or longer. Trials that included mild/moderate COPD patients showed that rehabilitation groups did significantly better than control groups with both short- and long-term rehabilitation programs.

CONCLUSION

COPD patients who receive rehabilitation have a better exercise capacity and they experience less shortness of breath than patients who do not receive rehabilitation. COPD patients may benefit from rehabilitation programs that include at least lower-extremity training. Patients with mild/moderate COPD benefit from short- and long-term rehabilitation, whereas patients with severe COPD may benefit from rehabilitation programs of at least 6 months.

Evidence-based medicine knowledge, attitudes, and skills of community faculty

CONTEXT

As medical schools turn to community physicians for ambulatory care teaching, assessing the preparation of these faculty in principles of evidence-based medicine (EBM) becomes important.

OBJECTIVE

To determine the knowledge and attitudes of community faculty concerning EBM and their use of EBM in patient care and teaching.

DESIGN

Cross-sectional survey conducted from January to March of 2000.

SETTING

A clinical campus of a state medical school; a midwestern city of a half-million people with demographics close to national means.

MAIN OUTCOME MEASURES

Comparisons of community faculty with full-time faculty in perceived importance and understanding of EBM (5-point scale), knowledge of EBM, and use of EBM in patient care and teaching.

MAIN RESULTS

Responses were obtained from 63% (177) of eligible community faculty and 71% (22) of full-time faculty. Community faculty considered EBM skills to be less important for daily practice than did full-time faculty (3.1 vs 4.0; P < .01). Primary care community faculty were less confident of their EBM knowledge than were subspecialty community or full-time faculty (2.9 vs 3.3 vs 3.6; P < .01). Objective measures of EBM knowledge showed primary care and subspecialty community faculty about equal and significantly below full-time faculty (P < .01). Thirty-three percent of community faculty versus 5% of full-time faculty do not incorporate EBM principles into their teaching (P < .01).

CONCLUSIONS

Community faculty are not as equipped or motivated to incorporate EBM into their clinical teaching as are full-time faculty. Faculty development programs for community faculty should feature how to use and teach basic EBM concepts.

Determining the predictors of internal medicine residency accreditation: what they do (not what they say)

PURPOSE

The Accreditation Council for Graduate Medical Education and the Residency Review Committee for Internal Medicine (RRC-IM) evaluate internal medicine residency programs using a list of 301 program requirements. The authors investigated which requirements, program demographics, and site-visitor characteristics were the strongest predictors of accreditation.

METHOD

The authors surveyed the program directors of all 405 accredited internal medicine residency programs in February 1998, obtaining data on the duration of the accreditation process, site visitors, and number and quality of citations. They also requested a copy of the notification letter containing citations and length of time until the next accreditation site visit (cycle length).

RESULTS

A total of 217 responses (54%) was received. The mean cycle length was 3.0 years, and the accreditation process averaged 14.5 months. Smaller programs had a shorter average cycle length. Site visitors were reported to be prepared and professional overall. However, site visitors with the lowest evaluations by program directors were associated with shorter cycle lengths. Four program characteristics and program citations accounted for 60% of the variation in cycle length: total number of citations in the notification letter, percentage of graduates passing the American Board of Internal Medicine Certifying Examination, inadequate demonstration of resident scholarship, and inadequate ambulatory care experience.

CONCLUSION

The authors devised an independent mechanism for determining the duration of the RRC-IM review process, influence of program demographics on the process, influence of site visitors on the accreditation action, and program requirements having the greatest effect on cycle length.

Utility of palmtop computers in a residency program: a pilot study

BACKGROUND

With advancing technology and flourishing medical information on the Internet, we studied the use of palmtop (handheld) computers by internal medicine residents.

METHODS

At a university-community hospital consortium, nine internal medicine residents and their program director participated in an 8-month cohort pilot study using palmtop computers with desktop synchronization and Internet access capabilities.

RESULTS

After 2 months of use, the residents had found a variety of uses for palmtop computers, such as the calendar, downloading residency-provided medical information, taking lecture notes, using a spreadsheet for common formulas, Internet/MEDLINE searching with modem access, infrared file transfer, downloading call schedules, and patient tracking. At 8 months, the residents were comfortable using palmtops on a daily basis. Technical difficulties included cumbersome modem cords, incompatible platforms and difficult Internet access at times, finding analog telephone lines in the hospital, and synchronization with home computers.

CONCLUSION

Palmtop computers are useful in the residency setting, and residents are capable of devising ways to use palmtops to suit their individual needs.

Benchmarks of support in internal medicine residency training programs

PURPOSE

To identify benchmarks of financial and staff support in internal medicine residency training programs and their correlation with indicators of quality.

METHOD

A survey instrument to determine characteristics of support of residency training programs was mailed to each member program of the Association of Program Directors of Internal Medicine. Results were correlated with the three-year running average of the pass rates on the American Board of Internal Medicine certifying examination using bivariate and multivariate analyses.

RESULTS

Of 394 surveys, 287 (73%) were completed: 74% of respondents were program directors and 20% were both chair and program director. The mean duration as program director was 7.5 years (median = 5), but it was significantly lower for women than for men (4.9 versus 8.1; p =.001). Respondents spent 62% of their time in educational and administrative duties, 30% in clinical activities, 5% in research, and 2% in other activities. Most chief residents were PGY4s, with 72% receiving compensation additional to base salary. On average, there was one associate program director for every 33 residents, one chief resident for every 27 residents, and one staff person for every 21 residents. Most programs provided trainees with incremental educational stipends, meals while oncall, travel and meeting expenses, and parking. Support from pharmaceutical companies was used for meals, books, and meeting expenses. Almost all programs provided meals for applicants, with 15% providing travel allowances and 37% providing lodging. The programs' board pass rates significantly correlated with the numbers of faculty fulltime equivalents (FTEs), the numbers of resident FTEs per office staff FTEs, and the numbers of categorical and preliminary applications received and ranked by the programs in 1998 and 1999. Regression analyses demonstrated three independent predictors of the programs' board pass rates: number of faculty (a positive predictor), percentage of clinical work performed by the program director (a negative predictor), and financial support from pharmaceutical companies (also a negative predictor).

CONCLUSIONS

These results identify benchmarks of financial and staff support provided to internal medicine residency programs. Some of these benchmarks are correlated with board pass rate, an accepted indicator of quality in residency training. Program directors and chairs can use this information to identify areas that may benefit from enhanced financial and administrative support.

Job turnover and its correlates among residency program directors in internal medicine: a three-year cohort study

PURPOSE

In 1983, 43% of internal medicine residency program directors had held their positions for less than three years. The purposes of this study were to determine the job turnover rate for internal medicine program directors, and the characteristics of program directors and residency programs that are associated with job turnover.

METHOD

In October 1996, questionnaires were sent to all non-military internal medicine residency program directors in the continental United States listed by the Accreditation Council for Graduate Medical Education (ACGME). The questionnaire covered demographics, program characteristics, and job satisfaction. In October 1999, an updated ACGME list was used to contact programs to verify changes in program directors and determine the dates of change.

RESULTS

A total of 262 usable responses were received. At the beginning of the study, 49% of the respondents had been on the job for three years or less, and 74 (29%) were no longer program directors three years later. Overall job satisfaction was highly associated (p <.01) with turnover. Multivariate Cox regression modeling yielded four variables independently associated with turnover: low satisfaction with colleague relationships (hazard ratio = 3.2, 95% CI = 1.6-6.4), a high percentage of administrative work time (HR = 2.9, 95% CI = 1.4-6.2), perceiving the job as a "stepping stone" (HR = 1.8, 95% CI = 1.0-3.2), and having had formal training to deal with problem residents (HR = 0.6, 95% CI = 0.4-1.1). Respondents with burnout, with the titles of program director and chair or department chief, and with less than two years on the job had nonsignificant trends toward job turnover. Variables not associated with turnover included gender, rank, salary, and program size.

CONCLUSIONS

Yearly turnover for internal medicine residency program directors is substantial. The four independent predictors of turnover identified in this study should be of interest to institutions recruiting or retaining program directors and to aspiring program directors.

Health information in material safety data sheets for a chemical which causes asthma

OBJECTIVE

To assess the quality of health information on material safety data sheets (MSDS) for a workplace chemical that is well known to cause or exacerbate asthma (toluene diisocyanate, TDI).

DESIGN

We reviewed a random sample of 61 MSDSs for TDI products produced by 30 manufacturers.

MEASUREMENTS AND MAIN RESULTS

Two physicians independently abstracted data from each MSDS onto a standardized audit form. One manufacturer provided no language about any respiratory effects of TDI exposure. Asthma was listed as a potential health effect by only 15 of the 30 manufacturers (50%). Listing asthma in the MSDS was associated with higher toluene diisocyanate concentrations in the product (P <.042). Allergic or sensitizing respiratory reactions were listed by 21 manufacturers (70%).

CONCLUSIONS

Many MSDSs for toluene diisocyanate do not communicate clearly that exposure can cause or exacerbate asthma. This suggests that physicians should not rely on the MSDS for information about health effects of this chemical.

Maximizing the use of a Web-based teaching skills curriculum for community-based volunteer faculty

BACKGROUND

The University of Kansas School of Medicine in Wichita created an Internet-based faculty development curriculum for community-based faculty. Because relatively few physicians use Internet-based continuing medical education (CME), the most cost-effective methods of encouraging use need to be identified.

METHOD

Five interventions intended to increase use of the curriculum were assessed. The number of times the CME curriculum Webpages were accessed was correlated with the interventions.

RESULTS

Demonstrating the Website to faculty at a semiannual meeting elicited the most Website "hits." Electronic mail and flyers also appeared to be effective in stimulating interest in the Website. Only four community-based faculty applied for CME credit for completing the curricular modules.

FINDINGS

Multiple modalities should be used in advertising and stimulating interest in an Internet-based faculty development curriculum. Demonstrating the Website to faculty at a meeting appeared to achieve the greatest return. Offering CME credit was not helpful in stimulating interest.

A job-satisfaction measure for internal medicine residency program directors

PURPOSE

To develop a job-satisfaction measure that encompasses the multifaceted job of internal medicine residency program directors.

METHOD

Questions were devised to measure program directors satisfaction with various facets of their jobs. In 1996, the authors surveyed all non-military internal medicine program directors in the United States.

RESULTS

Of the program directors surveyed, 301 (78%) responded. More respondents than non-respondents held the title of department chairperson in addition to the title of program director (22% vs 7%). Factor analysis and correlation analysis yielded a multifaceted measure (termed PD-Sat) composed of 20 questions and six facets (work with residents, colleague relationships, resources, patient care, pay, and promotion) that made sense based on literature review and discussions with program directors (face validity). The PD-Sat had good internal reliability (Cronbach's alpha = .88), as had each of its six facets (Cronbach's alphas = .60-.90). The six facets correlated modestly with one another (Pearson's r2 = .12-.67), suggesting they were measuring different aspects of a common concept. The PD-Sat correlated significantly with an established four-question global job-satisfaction scale used in previous studies (Pearson's r2 = .33) demonstrating concurrent validity. Scores on the PD-Sat predicted whether program directors were considering, seeking, or making a job change (predictive validity). The PD-Sat performed comparably well in subsets of program directors who were and were not department chairs, suggesting that it might be applicable to different populations of program directors.

CONCLUSION

The authors have developed a new facet-specific job-satisfaction measure that is reliable and valid for assessing the job satisfaction of internal medicine program directors. Because job descriptions for program directors in other specialties are similar, it may also be useful in these populations.

Promotion criteria for clinician-educators in the United States and Canada. A survey of promotion committee chairpersons

CONTEXT

Clinician-educators have concerns about their ability to be promoted and the criteria used by medical school promotion committees.

OBJECTIVE

To discover the criteria and methods that medical school promotion committees use to make decisions about the promotion of clinician-educators.

METHODS

In June 1996 we mailed a questionnaire to chairpersons of all medical school promotion committees in the United States and Canada.

RESULTS

Of 142 schools surveyed, 115 (81%) responded; 45% of respondents had a clinician-educator promotion track. On a scale from 1 (minimally important) to 7 (extremely important), the mean importance ratings of aspects of clinician-educators' performance were the following: teaching skills (6.3), clinical skills (5.8), mentoring (5.7), academic administration (5.3), developing educational programs (5.3), nonresearch scholarship (5.1), clinical research (4.8), service coordination (4.7), and education research (4.5). Methods to evaluate each aspect of performance were rated by respondents for importance and frequency of use. The 4 most important methods for evaluating teaching were awards, peer evaluation, learner evaluation, and teaching portfolio; 70% or more of schools used these frequently or always. The 4 most important methods of evaluating clinical skills were peer evaluation, awards, trainee evaluation, and objective measures, which were used frequently or always by 78%, 65%, 58%, and 29% of schools, respectively. Clinician-educators were expected to have fewer peer-reviewed publications to be promoted than investigators (5.7 vs 10.6, P<.001). Schools with separate clinician-educator tracks differed little in survey responses from schools without such tracks.

CONCLUSION

Most, but not all, promotion committees now assign high importance to the special contributions of clinician-educators and use a variety of methods to assess these, regardless of whether they have a separate clinician-educator promotion track.