Leaders' Perspectives on Resources for Academic Success: Defining Clinical Effort, Academic Time, and Faculty Support

INTRODUCTION

For academic promotion, clinical faculty are expected to excel in clinical care, teaching, and scholarship. Ensuring adequate protected time and resources to engage in scholarly work in the face of competing clinical responsibilities is critical. The authors examined academic leaders' perspectives across affiliate hospitals of a large medical school regarding the definition of clinical full-time effort and academic time, best practices to enable academic success, and barriers to faculty advancement.

METHODS

Open-ended, semistructured, individual interviews were conducted with a purposive sample of clinical department and division heads. Interview data were examined to illuminate the range and commonalities in practices and to identify successful approaches.

RESULTS

Interviews were conducted with 17 academic leaders across 6 affiliate hospitals. There was considerable variability in clinical full-time effort definition. "Academic time," more accurately characterized as "nonclinical time," was typically 1 day a week for nonshift specialties and mostly used for administrative work or completing clinical documentation. Certain departments were more explicit in designating and protecting time for academic pursuits; some had invested resources in intensive programs for academic advancement with built-in expectations for accountability. The impact of documentation burden was considerable in certain departments.

DISCUSSION AND CONCLUSION

Marked variability exists in time allocations for clinical and academic work, as well as in resources for academic success. This supports the potential value of establishing standards for defining and protecting academic time, motivating clinical faculty to engage in academic work, and building accountability expectations. Sharing best practices and setting standards may enhance academic advancement. Strategies to reduce documentation burden may enhance wellness.

It Is Time for Zero Tolerance for Sexual Harassment in Academic Medicine

While more women are in leadership positions in academic medicine now than ever before in U.S. history, evidence from recent surveys of women and graduating medical students demonstrates that sexual harassment continues in academic health centers. Academic medicine's ability to change its culture is hampered by victims' fear of reporting episodes of harassment, which is largely due to fear of retaliation. In this Perspective, the authors describe efforts in scientific societies to address the issue of sexual harassment and to begin to establish safe environments at national meetings. The authors contend that each institution must work to make it safe for individuals to come forward, to provide training for victims and for bystanders, and to abolish "locker room" talk that is demeaning to women.

Should We Treat for Subclinical Hypothyroidism?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

In May 2015, the U.S. Preventive Services Task Force issued a guideline on screening for thyroid disease that included a systematic evidence review and an update of its 2004 recommendations. The review assessed the effect of treating screen-detected subclinical thyroid dysfunction on health outcomes. It found adequate evidence that treating subclinical hypothyroidism does not provide clinically meaningful improvements in blood pressure, body mass index, bone mineral density, lipid levels, or quality-of-life measures. The review also concluded that evidence was inadequate to determine whether screening for thyroid dysfunction reduced cardiovascular disease or related morbidity and mortality. In separate guidelines, the American Association of Clinical Endocrinologists and American Thyroid Association advocated aggressive case-finding and recommended screening persons with certain clinical conditions or characteristics rather than the general population. These societies argue that subclinical hypothyroidism adversely affects cardiovascular outcomes and thus merits case-finding. Here, 2 experts discuss their perspectives on whether treating subclinical hypothyroidism reduces morbidity and mortality, whether there are harms of treatment, and how they would balance the benefits and harms of treatment both in general and for a specific patient.

Separating Residents' Inpatient and Outpatient Responsibilities: Improving Patient Safety, Learning Environments, and Relationships With Continuity Patients

PROBLEM

Current regulations for internal medicine residency programs require scheduling that minimizes conflict between inpatient and outpatient responsibilities. To meet these regulations, the internal medicine residency program at Beth Israel Deaconess Medical Center implemented a unique scheduling model--the Alternating Call and Elective Scheduling (ACES) model-in July 2009.

APPROACH

Beginning in academic year 2009-2010, the authors restructured schedules for their 95 postgraduate year 2 and 3 internal medicine residents using the ACES model. They report pre- and postimplementation housestaff responses from end-of-year program evaluation and culture-of-safety surveys, as well as residents' pre- and postintervention schedule and patient visit data.

OUTCOMES

Prior to the intervention, 13/83 (16%) residents agreed that the structure of residency training minimized conflict between inpatient and outpatient responsibilities; after the intervention, 82/84 (98%) agreed with this statement. Before the intervention, 23/83 (28%) residents felt that the schedule promoted inpatient safety, compared with 83/84 (99%) after the intervention. Agreement that the schedule promoted outpatient safety went from 28/83 (34%) preintervention to 73/84 (87%) postintervention. Before the intervention, 45/84 (54%) residents felt that the schedule promoted a continuous healing relationship with continuity patients, compared with 67/84 (80%) after the intervention. After implementation, residents' continuity visits with their own patients increased by 14%, and total annual patient visits increased by 16%.

NEXT STEPS

Separating residents' inpatient and outpatient responsibilities may improve patient safety, the learning environment, and resident-patient relationships. Future innovations might focus on improving patient safety and decreasing stress in the outpatient environment.

A review of the medical education literature for graduate medical education teachers

BACKGROUND

A rapidly evolving body of literature in medical education can impact the practice of clinical educators in graduate medical education.

OBJECTIVE

To aggregate studies published in the medical education literature in 2011 to provide teachers in general internal medicine with an overview of the current, relevant medical education literature.

REVIEW

We systematically searched major medical education journals and the general clinical literature for medical education studies with sound design and relevance to the educational practice of graduate medical education teachers. We chose 12 studies, grouped into themes, using a consensus method, and critiqued these studies.

RESULTS

Four themes emerged. They encompass (1) learner assessment, (2) duty hour limits and teaching in the inpatient setting, (3) innovations in teaching, and (4) learner distress. With each article we also present recommendations for how readers may use them as resources to update their clinical teaching. While we sought to identify the studies with the highest quality and greatest relevance to educators, limitation of the studies selected include their single-site and small sample nature, and the frequent lack of objective measures of outcomes. These limitations are shared with the larger body of medical education literature.

CONCLUSIONS

The themes and the recommendations for how to incorporate this information into clinical teaching have the potential to inform the educational practice of general internist educators as well as that of teachers in other specialties.

Succeeding as a Clinician Educator: useful tips and resources

Clinician Educators (CEs) play an essential role in the education and patient care missions of academic medical centers. Despite their crucial role, academic advancement is slower for CEs than for other faculty. Increased clinical productivity demands and financial stressors at academic medical centers add to the existing challenges faced by CEs. This perspective seeks to provide a framework for junior CEs to consider with the goal of maximizing their chance of academic success. We discuss six action areas that we consider central to flourishing at academic medical centers: 1. Clarify what success means and define goals; 2. Seek mentorship and be a responsible mentee; 3. Develop a niche and engage in relevant professional development; 4. Network; 5. Transform educational activities into scholarship; and 6. Seek funding and other resources.

Electronic medical record reminders and panel management to improve primary care of elderly patients

BACKGROUND

Most elderly patients do not receive recommended preventive care, acute care, and care for chronic conditions.

METHODS

We conducted a controlled trial to assess the effectiveness of electronic medical record (EMR) reminders, with or without panel management, on health care proxy designation, osteoporosis screening, and influenza and pneumococcal vaccinations in patients older than 65 years. Physicians were assigned to 1 of the following 3 arms: EMR reminder, EMR reminder plus panel manager, or control. We assessed completion of recommended practices during a 1-year period.

RESULTS

Among patients who had not already received the recommended care, health care proxy was designated in 6.5% of patients in the control arm, 8.8% of the EMR reminder arm, and 19.7% of the EMR reminder plus panel manager arm (P=.002). Bone density screening was completed in 17.7% of patients in the control arm, 19.7% of the EMR reminder arm, and 30.5% of the EMR reminder plus panel manager arm (P=.02). Pneumococcal vaccine was given to 13.1% of patients in the control arm, 19.5% of the EMR reminder arm, and 25.6% of the EMR reminder plus panel manager arm (P=.02). Influenza vaccine was given to 46.8% of patients in the control arm, 56.5% of the EMR reminder arm, and 59.7% of the EMR reminder plus panel manager arm (P=.002). Results were similar when adjusted for individual physician performance in the preceding year, patient age, patient sex, years cared for by the practice, and number of visits.

CONCLUSIONS

Electronic medical record reminders alone facilitated improvement in vaccination rates and, when augmented by panel management, facilitated further improvement in vaccination rates and boosted the rates of health care proxy designation and bone density screening.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01313169.

Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors

BACKGROUND

Many have called for ambulatory training redesign in internal medicine (IM) residencies to increase primary care career outcomes. Many believe dysfunctional, clinic environments are a key barrier to meaningful ambulatory education, but little is actually known about the educational milieu of continuity clinics nationwide.

OBJECTIVE

We wished to describe the infrastructure and educational milieu at resident continuity clinics and assess clinic readiness to meet new IM-RRC requirements.

DESIGN

National survey of ACGME accredited IM training programs.

PARTICIPANTS

Directors of academic and community-based continuity clinics.

RESULTS

Two hundred and twenty-one out of 365 (62%) of clinic directors representing 49% of training programs responded. Wide variation amongst continuity clinics in size, structure and educational organization exist. Clinics below the 25th percentile of total clinic sessions would not meet RRC-IM requirements for total number of clinic sessions. Only two thirds of clinics provided a longitudinal mentor. Forty-three percent of directors reported their trainees felt stressed in the clinic environment and 25% of clinic directors felt overwhelmed.

LIMITATIONS

The survey used self reported data and was not anonymous. A slight predominance of larger clinics and university based clinics responded. Data may not reflect changes to programs made since 2008.

CONCLUSIONS

This national survey demonstrates that the continuity clinic experience varies widely across IM programs, with many sites not yet meeting new ACGME requirements. The combination of disadvantaged and ill patients with inadequately resourced clinics, stressed residents, and clinic directors suggests that many sites need substantial reorganization and institutional commitment.New paradigms, encouraged by ACGME requirement changes such as increased separation of inpatient and outpatient duties are needed to improve the continuity clinic experience.

Combining clinical microsystems and an experiential quality improvement curriculum to improve residency education in internal medicine

Beth Israel Deaconess Medical Center's internal medicine residency program was admitted to the new Education Innovation Project accreditation pathway of the Accreditation Council of Graduate Medical Education to begin in July 2006. The authors restructured the inpatient medical service to create clinical microsystems in which residents practice throughout residency. Program leadership then mandated an active curriculum in quality improvement based in those microsystems. To provide the experience to every graduating resident, a core faculty in patient safety was trained in the basics of quality improvement. The authors hypothesized that such changes would increase the number of residents participating in quality improvement projects, improve house officer engagement in quality improvement work, enhance the culture of safety the residents perceive in their training environment, improve work flow on the general medicine ward rotations, and improve the overall educational experience for the residents on ward rotations.The authors describe the first 18 months of the intervention (July 2006 to January 2008). The authors assessed attitudes and the educational experience with surveys and evaluation forms. After the intervention, the authors documented residents' participation in projects that overlapped with hospital priorities. More residents reported roles in designing and implementing quality improvement changes. Residents also noted greater satisfaction with the quality of care they deliver. Fewer residents agreed or strongly agreed that the new admitting system interfered with communication. Ongoing residency program assessment showed an improved perception of workload, and educational ratings of rotations improved. The changes required few resources and can be transported to other settings.

Secondary symptomatic parvovirus B19 infection in a healthy adult

Parvovirus B19 is a common infection in adults and children. There are reports of secondary parvovirus infection in immunocompromised persons, but no reports of symptomatic secondary infection in healthy persons. We describe a healthy 39-year-old woman who presented with fever, rash, and arthralgia. Her symptoms were thought most compatible with parvovirus B19 infection, but she reported prior positive parvovirus antibody 2 years earlier during prenatal care. Tests were therefore also sent for HIV, streptococcal infection, hepatitis C, and Lyme disease. Testing revealed both elevated IgG and IgM antibodies for parvovirus B19; previously, the patient was positive only for IgG. On a subsequent visit she related that a community outbreak of parvovirus developed in her town and church group. We believe this case demonstrates that a symptomatic secondary infection with parvovirus can occur in healthy persons, and that prior positive antibody test does not preclude the development of acute infection.

Physicians' attitudes toward using patient reports to assess quality of care

PURPOSE

Patients' reports about their care, including reports about specific physician behaviors, are increasingly being used to assess quality of care. The authors surveyed physicians in an academic environment about their attitudes concerning possible uses of these reports.

METHOD

A survey was conducted of the 540 hospital- and community-based internists and housestaff at Beth Israel Hospital in Boston, Massachusetts, in 1993-94. The survey instrument included seven items designed to assess the physicians' views about potential uses of patient reports about their care. The physicians were asked to rate the items on a five-point scale (ranging from "strongly agree" to "strongly disagree").

RESULTS

A total of 343 (64%) of the physicians responded. Eighty-six percent agreed that patient judgments are important in assessing quality of care. There was widespread agreement with four potential uses of patient judgments: for changing a specific physician behavior (94% agreed), for receiving feedback from patients (90%), for use in physician education programs (81%), and for evaluating students and housestaff (72%). However, far fewer of the physicians agreed with two uses over which physicians would have less control: publishing judgments to help patients select physicians (28% agreed) and the use of judgments to influence physician compensation (16%). While the housestaff were less likely to agree with the use of patient reports in housestaff evaluations, the housestaff and faculty had similar opinions about all the other potential uses.

CONCLUSION

The physicians believed that patients' reports about experiences with their physicians are valid indicators of quality. They responded that they would accept using these reports to improve care when the uses are nonthreatening and within the control of physicians. In contrast, there was far less support when the uses are external to physician control and potentially threatening.

Trichobezoar associated with gastric polyposis

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Medical risks of cocaine use

This discussion was selected from the weekly Grand Rounds in the Department of Medicine, Oregon Health Sciences University School of Medicine, Portland. Taken from a transcription, it has been edited by George A. Porter, MD, Professor and Chair, Department of Medicine.