A Learning Community Supporting Experiential Education to Learn About Healthcare Equity Quality Improvement

BACKGROUND

Quality improvement (QI) for healthcare equity (HCE) is an important aspect of graduate medical education (GME), but there is limited published research on educational programs teaching this topic.

AIM

To describe and evaluate a novel curriculum and learning community for HCE QI.

SETTING

Academic institution.

PARTICIPANTS

Forty-eight participants: 32 learners and 16 faculty.

PROGRAM DESCRIPTION

This novel, longitudinal curriculum utilized a virtual hub-and-spoke learning community. Five interdepartmental teams of learners and faculty (spokes) used QI methods to address an existing institutional healthcare inequity (HCI). A team of experts (the hub) led monthly group meetings to foster the learning community and guide teams.

PROGRAM EVALUATION

Retrospective pre-post curricular surveys assessed participant satisfaction, knowledge, and skills in applying QI methods to address HCIs. Response rate was 33%. The majority of participants (92.4%) reported an increase in knowledge and skills in conducting QI for HCIs. All participants reported an increased likelihood of future engagement in HCE QI. Final QI projects average QIPAT7 score was 25.8 (SD = 4.93), consistent with "meets expectations" in most categories.

DISCUSSION

This program is a feasible model to teach GME learners and faculty about HCE QI and may be adopted by other institutions.

Resident Mental Health Care: a Timely and Necessary Resource

OBJECTIVE

Residency training is associated with stress and burnout that can contribute to poor mental health, yet many residents do not get the help needed. While some healthcare institutions provide mental health services specifically for residents, literature has documented few examples. The objective of this study was to investigate the utilization and patient characteristics of a resident mental health program.

METHODS

The authors conducted a retrospective records analysis of residents who utilized outpatient mental health services through the Thomas Jefferson University Hospital Emotional Health and Wellness Program for House Staff from 2010 to 2018.

RESULTS

A total of 158 resident patient charts were reviewed. Utilization was highest for females, first years, and general internal medicine residents. Initial help-seeking was most common for summer, winter, and intern year. The most frequent diagnoses were adjustment, depressive, and anxiety disorders. Of residents who completed screening tools, 43% screened positive for moderate to severe depression, 11% screened positive for hazardous alcohol consumption, and 15% endorsed thoughts of death or suicide.

CONCLUSIONS

Resident physicians manifest psychiatric symptoms, mental disorders, and suicidal ideation that require treatment and intervention. Yet, a minority of residents make use of services. This data emphasizes the need to promote help-seeking behaviors among residents and ensure timely access to comprehensive mental health services.

Peer Discussion Decreases Practice Intensity and Increases Certainty in Clinical Decision-Making Among Internal Medicine Residents

BACKGROUND

Team-based decision-making has been shown to reduce diagnostic error, increase clinical certainty, and decrease adverse events.

OBJECTIVE

This study aimed to assess the effect of peer discussion on resident practice intensity (PI) and clinical certainty (CC).

METHODS

A vignette-based instrument was adapted to measure PI, defined as the likelihood of ordering additional diagnostic tests, consultations or empiric treatment, and CC. Internal medicine residents at 7 programs in the Philadelphia area from April 2018 to June 2019 were eligible for inclusion in the study. Participants formed groups and completed each item of the instrument individually and as a group with time for peer discussion in between individual and group responses. Predicted group PI and CC scores were compared with measured group PI and CC scores, respectively, using paired t testing.

RESULTS

Sixty-nine groups participated in the study (response rate 34%, average group size 2.88). The measured group PI score (2.29, SD = 0.23) was significantly lower than the predicted group PI score (2.33, SD = 0.22) with a mean difference of 0.04 (SD = 0.10; 95% CI 0.02-0.07; P = .0002). The measured group CC score (0.493, SD = 0.164) was significantly higher than the predicted group CC score (0.475, SD = 0.136) with a mean difference of 0.018 (SD = 0.073; 95% CI 0.0006-0.0356; P = .022).

CONCLUSIONS

In this multicenter study of resident PI, peer discussion reduced PI and increased CC more than would be expected from averaging group members' individual scores.

A Shifting Paradigm: The Role of Focused Cardiac Ultrasound in Bedside Patient Assessment

Transthoracic echocardiography is the standard of care in anatomic and functional cardiovascular assessment; however, focused cardiac ultrasound (FoCUS) performed with portable ultrasound equipment is increasingly being used as an adjunct to comprehensive history and physical examination. FoCUS assessments, unlike formal echocardiography, are intended to assist physicians in answering explicit clinical questions with a narrow differential diagnosis in real time. Over the past decade, a growing body of literature has repeatedly shown the value that FoCUS adds to clinical evaluation. Specifically, FoCUS improves point-of-care diagnostic accuracy, which in turn modifies treatment plans, decreases time to diagnosis, and reduces resource utilization. Although less robust, there is also evidence showing improvement in clinical outcomes. Based on this evidence, clinicians, training programs, and clinical societies have embraced FoCUS as a tool to complement bedside patient evaluation. Herein, we review the evidence for FoCUS in clinical practice, specifically evaluating the diagnostic accuracy, the impact on clinical decision-making, and the effect on clinical outcomes.

The Vice Chair of Education in Emergency Medicine: A Workforce Study to Establish the Role, Clarify Responsibilities, and Plan for Success

OBJECTIVES

Despite increasing prevalence in emergency medicine (EM), the vice chair of education (VCE) role remains ambiguous with regard to associated responsibilities and expectations. This study aimed to identify training experiences of current VCEs, clarify responsibilities, review career paths, and gather data to inform a unified job description.

METHODS

A 40-item, anonymous survey was electronically sent to EM VCEs. VCEs were identified through EM chairs, residency program directors, and residency coordinators through solicitation e-mails distributed through respective listservs. Quantitative data are reported as percentages with 95% confidence intervals and continuous variables as medians with interquartiles (IQRs). Open- and axial-coding methods were used to organize qualitative data into thematic categories.

RESULTS

Forty-seven of 59 VCEs completed the survey (79.6% response rate); 74.4% were male and 89.3% were white. Average time in the role was 3.56 years (median = 3.0 years, IQR = 4.0 years), with 74.5% serving as inaugural VCE. Many respondents held at least one additional administrative title. Most had no defined job description (68.9%) and reported no defined metrics of success (88.6%). Almost 78% received a reduction in clinical duties, with an average reduction of 27.7% protected time effort (median = 27.2%, IQR = 22.5%). Responsibilities thematically link to faculty affairs and promotion of the departmental educational mission and scholarship.

CONCLUSION

Given the variability in expectations observed, the authors suggest the adoption of a unified VCE job description with detailed responsibilities and performance metrics to ensure success in the role. Efforts to improve the diversity of VCEs are encouraged to better match the diversity of learners.

Patient Safety Escape Room: A Graduate Medical Education Simulation for Event Reporting

INTRODUCTION

Although residents are on the front lines of patient care, they enter few formal patient safety reports on the adverse events and near misses they witness. Demonstrating the rationale and mechanics of reporting may improve this.

METHODS

We designed and implemented an escape room patient safety simulation to incorporate active learning, gamification, and adult learning theory into intern patient safety onboarding. Interns from all sponsoring institution programs participated, identifying, mitigating, and reporting a range of patient safety hazards. Props and faculty time were the major resources required.

RESULTS

One hundred twenty interns participated in this simulation in June 2018. Forty-one percent reported previous training on reporting errors, and only 5% had previously entered an event report. Average confidence in ability to identify patient safety hazards improved after the simulation from 6.35 to 8.00 on a 10-point rating scale. The simulation was rated as relevant or highly relevant to practice by 96% of interns.

DISCUSSION

Several factors contribute to a low error-reporting rate among house staff. We developed a simulation modeled on popular escape room activities to increase awareness of safety hazards and ensure familiarity with the actual online reporting system our interns will use in the clinical environment.

Specialty and Lifestyle Preference Changes during Medical School

PURPOSE

Medical student specialty choices have significant downstream effects on the availability of physicians and, ultimately, the effectiveness of health systems. This study investigated how medical student specialty preferences change over time in relation to their demographics and lifestyle preferences.

METHOD

Students from ten medical schools were surveyed at matriculation (2012) and graduation (2016). The two surveys included questions about specialty and lifestyle preferences, demographics, educational background, and indebtedness. Student data from 2012 to 2016 were paired together and grouped into those whose specialty preferences remained constant or switched.

RESULTS

Response rates in 2012 and 2016 were 65% (997/1530) and 50% (788/1575), respectively. Fourth-year students ranked "enjoying the type of work I am doing" as less important to a good physician lifestyle than did first-year students (from 59.6 to 39.7%). The lifestyle factors "having control of work schedule" and "having enough time off work" were ranked as more important to fourth-year students than first-year students (from 15.6 to 18.2% and 14.8 to 31.9%, respectively). The paired dataset included 19% of eligible students (237/1226). Demographic and lifestyle factors were not significantly associated with specialty preference switching. Additionally, no significant association existed between changing lifestyle preferences and switching specialty preference (p = 0.85).

CONCLUSIONS

During the course of medical school, lifestyle preferences became more focused on day-to-day factors and less on deeper motivational factors. Neither demographics nor lifestyle preferences appear to relate to a student's decision to switch specialty preference during medical school. These findings represent an important step in uncovering causes of specialty preference trends.

Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysis

BACKGROUND

Incorporating focused cardiac ultrasonography (FoCUS) into clinical examination could improve the diagnostic yield of bedside patient evaluation.

PURPOSE

To compare the accuracy of FoCUS-assisted clinical assessment versus clinical assessment alone for diagnosing left ventricular dysfunction or valvular disease in adults having cardiovascular evaluation.

DATA SOURCES

English-language searches of MEDLINE, Embase, and Web of Science from 1 January 1990 to 23 May 2019 and review of reference citations.

STUDY SELECTION

Eligible studies were done in patients having cardiovascular evaluation; compared FoCUS-assisted clinical assessment versus clinical assessment alone for the diagnosis of left ventricular systolic dysfunction, aortic or mitral valve disease, or pericardial effusion; and used transthoracic echocardiography as the reference standard.

DATA EXTRACTION

Three study investigators independently abstracted data and assessed study quality.

DATA SYNTHESIS

Nine studies were included in the meta-analysis. The sensitivity of clinical assessment for diagnosing left ventricular dysfunction (left ventricular ejection fraction <50%) was 43% (95% CI, 33% to 54%), whereas that of FoCUS-assisted examination was 84% (CI, 74% to 91%). The specificity of clinical assessment was 81% (CI, 65% to 90%), and that of FoCUS-assisted examination was 89% (CI, 85% to 91%). The sensitivities of clinical assessment and FoCUS-assisted examination for diagnosing aortic or mitral valve disease (of at least moderate severity) were 46% (CI, 35% to 58%) and 71% (CI, 63% to 79%), respectively. Both the clinical assessment and the FoCUS-assisted examination had a specificity of 94% (CI, 91% to 96%).

LIMITATION

Evidence was scant, persons doing ultrasonography had variable skill levels, and most studies had unclear or high risk of bias.

CONCLUSION

Clinical examination assisted by FoCUS has greater sensitivity, but not greater specificity, than clinical assessment alone for identifying left ventricular dysfunction and aortic or mitral valve disease; FoCUS-assisted examination may help rule out cardiovascular pathology in some patients, but it may not be sufficient for definitive confirmation of cardiovascular disease suspected on physical examination.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42019124318).

Finding the 'QR' to Patient Safety: Applying Gamification to Incorporate Patient Safety Priorities Through a Simulated 'Escape Room' Experience

Medical errors are the eighth leading cause of mortality in the United States and contribute to over one million preventable injuries. In an effort to prevent medical errors, reporting systems serve as invaluable tools to detect patient safety events and quality problems longitudinally. Historically, trainees (i.e., students and residents) rarely submit incident reports for encountered patient safety threats. The authors propose an immersive learning experience utilizing gamification theory and leveraging the increasingly popular ‘escape room’ to help resident trainees identify reportable patient safety priorities.

All 130 incoming intern physicians at the Thomas Jefferson University (Jefferson) were enrolled in the Patient Safety Escape Room study as part of their residency orientation (June 2018). The residents were randomly divided into 16 teams. Each team was immersed in a simulated escape room, tasked with identifying a predetermined set of serious patient safety hazards, and successfully manually entering them into the Jefferson Event Reporting System within the time allotted to successfully ‘win the game’ by ‘escaping the room’. Quick response (QR) codes were planted throughout the activity to provide in-game instructions; clues to solve the puzzle; and key information about patient safety priorities at Jefferson. All participants underwent a formal debriefing using the feedback capture grid method and completed a voluntary post-study survey, adapted from Brookfield’s Critical Incident Questionnaire (CIQ). The study was IRB exempt.

Thematic analysis of the post-activity CIQ survey (n = 102) revealed that interns were engaged during the immersive learning experience (n = 42) and were specifically engaged by having to independently identify patient safety threats (n = 30). Participants identified team role assignment (n = 52) and effective communication (n = 26) as the two most helpful actions needed to successfully complete the activity. Participants were overall surprised by the success of the education innovation (n = 45) and reported that it changed how they viewed patient safety threats. Areas for improvement include clearer game instructions and using a more streamlined event reporting process.

The escape room patient-safety activity allowed interns to actively engage in an innovative orientation activity that highlighted the importance of patient safety hazards, as well as providing them with the opportunity to document event reports in real-time. Next steps will include longitudinally tracking the quantity of error reports entered by this cohort to determine the effectiveness of this educational intervention.

Leveraging Structural Changes in an Electronic Health Record Tool to Standardize Written Handoff

Miscommunications during patient handoff can lead to harm. The I-PASS bundle has been shown to improve safety outcomes. Although effective training reliably improves verbal handoffs, research has demonstrated a lack of effect on written handoffs. The objective was to compare written handoff before and after integration of a standardized electronic health record (EHR) tool. Interns at a large urban academic medical center underwent I-PASS handoff training. The EHR handoff tool was then revised to prompt the I-PASS components. Handoff documents were obtained before and after the intervention. More handoffs included Illness Severity (33% to 59%, P < .001) and Action List (65% to 83%, P = .005) after the intervention. There was no change in handoffs with miscommunications (12.5% to 10%, P = .566) or omissions (8% to 11%, P = .447). Handoffs including tangential or unrelated information decreased (20% to 4%, P = .001). A written handoff tool can reinforce the effect of training and increase adherence to I-PASS.

Utilization of Continuous Cardiac Monitoring on Hospitalist-led Teaching Teams

Guidelines for continuous cardiac monitoring (CCM) have focused almost exclusively on cardiac diagnoses, thus limiting their application to a general medical population. In this study, a retrospective chart review was performed to identify the reasons that general medical patients, cared for on hospitalist-led inpatient teaching teams between April 2017 and February 2018, were initiated and maintained on CCM, and to determine the incidence of clinically significant arrhythmias in this patient population. The three most common reasons for telemetry initiation were sepsis (24%), arrhythmias (12%), and hypoxia (10%). Most patients remained on telemetry for more than 48 hours (62%) and a significant number of patients were on telemetry until they were discharged from the hospital (39%). Of the cumulative total of more than 20,573 hours of CCM provided to this patient population, 37% of patients demonstrated only normal sinus rhythm and 3% had a clinically significant arrhythmia that affected management.

Assessing Correlations of Physicians' Practice Intensity and Certainty During Residency Training

BACKGROUND

Variation in physicians' practice patterns contributes to unnecessary health care spending, yet the influences of modifiable determinants on practice patterns are not known. Identifying these mutable factors could reduce unnecessary testing and decrease variation in clinical practice.

OBJECTIVE

To assess the importance of the residency program relative to physician personality traits in explaining variations in practice intensity (PI), the likelihood of ordering tests and treatments, and in the certainty of their intention to order.

METHODS

We surveyed 690 interns and residents from 7 internal medicine residency programs, ranging from small community-based programs to large university residency programs. The surveys consisted of clinical vignettes designed to gauge respondents' preferences for aggressive clinical care, and questions assessing respondents' personality traits. The primary outcome was the participant-level mean response to 23 vignettes as a measure of PI. The secondary outcome was a certainty score (CS) constructed as the proportion of vignettes for which a respondent selected "definitely" versus "probably."

RESULTS

A total of 325 interns and residents responded to the survey (47% response rate). Measures of personality traits, subjective norms, demographics, and residency program indicators collectively explained 27.3% of PI variation. Residency program identity was the largest contributor. No personality traits were significantly independently associated with higher PI. The same collection of factors explained 17.1% of CS variation. Here, personality traits were responsible for 63.6% of the explained variation.

CONCLUSIONS

Residency program affiliations explained more of the variation in PI than demographic characteristics, personality traits, or subjective norms.

The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors

PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care.

APPROACH

Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation.

FINDINGS

Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.

Lifestyle factors and primary care specialty selection: comparing 2012-2013 graduating and matriculating medical students' thoughts on specialty lifestyle

PURPOSE

To compare how first-year (MS1) and fourth-year students (MS4) ascribe importance to lifestyle domains and specialty characteristics in specialty selection, and compare students' ratings with their primary care (PC) interest.

METHOD

In March 2013, MS4s from 11 U.S. MD-granting medical schools were surveyed. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 lifestyle domains and 21 specialty selection characteristics. One-way analysis of variance was used to assess differences by PC interest among MS4s. Using logistic regression, ratings from MS4s were compared with prior analyses of ratings by MS1s who matriculated to the same 11 schools in 2012.

RESULTS

The response rate was 57% (965/1,701). MS4s, as compared with MS1s, rated as more important to good lifestyle: time off (4.3 versus 4.0), schedule control (4.2 versus 3.9), and financial compensation (3.4 versus 3.2). More MS4s than MS1s selected "time-off" (262/906 [30%] versus 136/969 [14%]) and "control of work schedule" (169/906 [19%] versus 146/969 [15%]) as the most important lifestyle domains. In both classes, PC interest was associated with higher ratings of working with the underserved and lower ratings of prestige and salary.

CONCLUSIONS

In the 2012-2013 academic year, matriculating students and graduating students had similar perceptions of lifestyle and specialty characteristics associated with PC interest. Graduating students placed more importance on schedule control and time off than matriculating students. Specialties should consider addressing a perceived lack of schedule control or inadequate time off to attract students.

Primary care, the ROAD less traveled: what first-year medical students want in a specialty

PURPOSE

Medical students are increasingly choosing non-primary-care specialties. Students consider lifestyle in selecting their specialty, but how entering medical students perceive lifestyle is unknown. This study investigates how first-year students value or rate lifestyle domains and specialty-selection characteristics and whether their ratings vary by interest in primary care (PC).

METHOD

During the 2012-2013 academic year, the authors conducted a cross-sectional survey of first-year medical students from 11 MD-granting medical schools. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 domains of good lifestyle and 21 characteristics related to specialty selection. The authors classified students into five groups by PC interest and assessed differences by PC interest using one-way analysis of variance.

RESULTS

Of 1,704 participants, 1,020 responded (60%). The option "type of work I am doing" was the highest-rated lifestyle domain (mean 4.8, standard deviation [SD] 0.6). "Being satisfied with the job" was the highest-rated specialty-selection characteristic (mean 4.7, SD 0.5). "Availability of practice locations in rural areas" was rated lowest (mean 2.0, SD 1.1). As PC interest decreased, the importance of "opportunities to work with underserved populations" also decreased, but importance of "average salary earned" increased (effect sizes of 0.98 and 0.94, respectively).

CONCLUSIONS

First-year students valued enjoying work. The importance of financial compensation was inversely associated with interest in PC. Examining the determinants of enjoyable work may inform interventions to help students attain professional fulfillment in PC.