Understanding suboptimal e-consult requests: lessons from the VA

OBJECTIVES

Electronic consultations, or e-consults, which are requests for specialist advice without direct patient interaction, are becoming increasingly common across health systems. We sought to identify clinicians' perspectives on the quality of e-consult requests that they send and receive.

STUDY DESIGN

A qualitative research study at the US Department of Veterans Affairs (VA) New England Healthcare System.

METHODS

We interviewed a total of 73 clinicians, including 38 specialists across 3 specialties (cardiology, neurology, pulmonology) and 35 primary care clinicians (PCCs), between March and June 2019. The interviews were analyzed using thematic analysis.

RESULTS

VA specialists and PCCs generally agreed that e-consult requests should be focused and precise, not require lengthy chart review, and include adequate preliminary workup results. At the same time, specialists expressed frustration with what they perceived as suboptimal e-consult requests. Interviewees attributed this gap to 3 factors: limitations of the electronic health record user interface, divergence between PCCs and specialists in the areas of expertise, and organizational pressures on the 2 groups.

CONCLUSIONS

VA clinicians' perspectives on suboptimal requests contain lessons that are broadly applicable to other health systems that seek to maximize the potential of e-consults to facilitate clinician collaboration and care coordination.

Implications of Electronic Consultations for Clinician Communication and Relationships: A Qualitative Study

BACKGROUND

Strong relationships and effective communication between clinicians support care coordination and contribute to care quality. As a new mechanism of clinician communication, electronic consultations (e-consults) may have downstream effects on care provision and coordination.

OBJECTIVE

The objective of this study was to understand primary care providers' and specialists' perspectives on how e-consults affect communication and relationships between clinicians.

RESEARCH DESIGN

Qualitative study using thematic analysis of semistructured interviews.

SUBJECTS

Six of 8 sites in the VISN 1 (Veterans Integrated Service Network) in New England were chosen, based on variation in organization and received e-consult volume. Seventy-three respondents, including 60 clinicians in primary care and 3 high-volume specialties (cardiology, pulmonology, and neurology) and 13 clinical leaders at the site and VISN level, were recruited.

MEASURES

Participants' perspectives on the role and impact of e-consults on communication and relationships between clinicians.

RESULTS

Clinicians identified 3 types of e-consults' social affordances: (1) e-consults were praised for allowing specialist advice to be more grounded in patient data and well-documented, but concerns about potential legal liability and increased transparency of communication to patients and others were also noted; (2) e-consults were perceived as an imperfect modality for iterative communication, especially for complex conversations requiring shared deliberation; (3) e-consults were understood as a factor influencing clinician relationships, but clinicians disagreed on whether e-consults promote or undermine relationship building.

CONCLUSIONS

Clinicians have diverse concerns about the implications of e-consults for communication and relationships. Our findings may inform efforts to expand and improve the use of e-consults in diverse health care settings.

Electronic consultations and economies of scale: a qualitative study of clinician perspectives on scaling up e-consult delivery

OBJECTIVE

To explore Veterans Health Administration clinicians' perspectives on the idea of redesigning electronic consultation (e-consult) delivery in line with a hub-and-spoke (centralized) model.

MATERIALS AND METHODS

We conducted a qualitative study in VA New England Healthcare System (VISN 1). Semi-structured phone interviews were conducted with 35 primary care providers and 38 specialty care providers, including 13 clinical leaders, at 6 VISN 1 sites varying in size, specialist availability, and e-consult volume. Interviews included exploration of the hub-and-spoke (centralized) e-consult model as a system redesign option. Qualitative content analysis procedures were applied to identify and describe salient categories.

RESULTS

Participants saw several potential benefits to scaling up e-consult delivery from a decentralized model to a hub-and-spoke model, including expanded access to specialist expertise and increased timeliness of e-consult responses. Concerns included differences in resource availability and management styles between sites, anticipated disruption to working relationships, lack of incentives for central e-consultants, dedicated staff's burnout and fatigue, technological challenges, and lack of motivation for change.

DISCUSSION

Based on a case study from one of the largest integrated healthcare systems in the United States, our work identifies novel concerns and offers insights for healthcare organizations contemplating a scale-up of their e-consult systems.

CONCLUSIONS

Scaling up e-consults in line with the hub-and-spoke model may help pave the way for a centralized and efficient approach to care delivery, but the success of this transformation will depend on healthcare systems' ability to evaluate and address barriers to leveraging economies of scale for e-consults.

Electronic consultations (E-consults) and their outcomes: a systematic review

OBJECTIVE

Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access, cost, quality, and patient and clinician experience and identified the gaps in existing research on these outcomes.

MATERIALS AND METHODS

We searched 4 databases for empirical studies published between 1/1/2015 and 2/28/2019 that reported on one or more outcomes of interest. Two investigators reviewed titles and abstracts. One investigator abstracted information from each relevant article, and another confirmed the abstraction. We applied the GRADE criteria for the strength of evidence for each outcome.

RESULTS

We found only modest empirical evidence for effectiveness of e-consults on important outcomes. Most studies are observational and within a single health care system, and comprehensive assessments are lacking. For those outcomes that have been reported, findings are generally positive, with mixed results for clinician experience. These findings reassure but also raise concern for publication bias.

CONCLUSION

Despite stakeholder enthusiasm and encouraging results in the literature to date, more rigorous study designs applied across all outcomes are needed. Policy makers need to know what benefits may be expected in what contexts, so they can define appropriate measures of success and determine how to achieve them.

Innovative Use Of Electronic Consultations In Preoperative Anesthesiology Evaluation At VA Medical Centers In New England

Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experienced a rapid increase in the use of anesthesiology e-consults: 5,023 were sent in 2015, compared with 103 in 2012. Uptake across sites varied from near-universal use of e-consults for preoperative assessment to use for only selected low-risk patients or no use. Interviews with stakeholders revealed considerable differences in the perceived impact of e-consults on workflow and patient-centeredness. Clinicians at sites with high use of e-consults noted that they improved workflow efficiency. In comparison, clinicians at sites with low use preferentially valued face-to-face visits for some or all patients. The adoption of a health information technology innovation can alter the process of care delivery, depending on perceptions of its value by key stakeholders.

Evaluating diverse electronic consultation programs with a common framework

Background

Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion.

Methods

Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems’ end-users.

Results

Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies.

Conclusion

A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3626-4) contains supplementary material, which is available to authorized users.

Cardiology electronic consultation (e-consult) use by primary care providers at VA medical centres in New England

INTRODUCTION

E-consultations (e-consults) were implemented at VA medical centers to improve access to specialty care. Cardiology e-consults are among the most commonly requested, but little is known about how primary care providers (PCPs) use cardiology e-consults to access specialty care.

METHODS

This is a retrospective analysis of 750 patients' medical charts with cardiology e-consults requested by medical providers (October 2013-September 2015) in the VA New England Healthcare System. We described the patients and referring provider characteristics, and e-consult questions. We reviewed cardiologists' responses and examined their recommendations.

RESULTS

Among the 424 e-consults requested from PCPs, 92.7% were used to request answers to clinical questions, while 7.3% were used for administrative purposes. Among the 393 e-consults with clinical questions, 60 e-consults were regarding preoperative management; these questions most commonly addressed general risk assessment (n = 44), anti-coagulation/anti-platelet management (n = 33), and EKG interpretation (n = 20). Cardiologists provided answers for the majority (89.6%) of clinical questions. Among the e-consults in which cardiologists did not provide answers or clinical guidance (n = 41), the reasons included missing or insufficient clinical information (n = 18), medical complexity (n = 6), and deferment to the patient's non-VA primary cardiologist (n = 7). Cardiologists recommended that the patients be seen as face-to-face consults for 7.9% of e-consults.

DISCUSSION

Primary care providers are the most frequent requesters of cardiology e-consults, using them primarily to obtain input on clinical questions. Cardiologists did not provide answers for one in ten, owing principally to insufficient available clinical information. Educating PCPs and standardizing the template for requesting e-consultation may help to reduce the number of unanswered e-consults.

A Team-Based Online Game Improves Blood Glucose Control in Veterans With Type 2 Diabetes: A Randomized Controlled Trial

OBJECTIVE

Rigorous evidence is lacking whether online games can improve patients' longer-term health outcomes. We investigated whether an online team-based game delivering diabetes self-management education (DSME) to patients via e-mail or mobile application (app) can generate longer-term improvements in hemoglobin A_1c (HbA_1c).

RESEARCH DESIGN AND METHODS

Patients (n = 456) on oral diabetes medications with HbA_1c ≥58 mmol/mol were randomly assigned between a DSME game (with a civics booklet) and a civics game (with a DSME booklet). The 6-month games sent two questions twice weekly via e-mail or mobile app. Participants accrued points based on performance, with scores posted on leaderboards. Winning teams and individuals received modest financial rewards. Our primary outcome measure was HbA_1c change over 12 months.

RESULTS

DSME game patients had significantly greater HbA_1c reductions over 12 months than civics game patients (-8 mmol/mol [95% CI -10 to -7] and -5 mmol/mol [95% CI -7 to -3], respectively; P = 0.048). HbA_1c reductions were greater among patients with baseline HbA_1c >75 mmol/mol: -16 mmol/mol [95% CI -21 to -12] and -9 mmol/mol [95% CI -14 to -5] for DSME and civics game patients, respectively; P = 0.031.

CONCLUSIONS

Patients with diabetes who were randomized to an online game delivering DSME demonstrated sustained and meaningful HbA_1c improvements. Among patients with poorly controlled diabetes, the DSME game reduced HbA_1c by a magnitude comparable to starting a new diabetes medication. Online games may be a scalable approach to improve outcomes among geographically dispersed patients with diabetes and other chronic diseases.

Electronic Consultations (E-consults): Advancing Infectious Disease Care in a Large Veterans Affairs Healthcare System

The impact of e-consults on total consultative services was evaluated. After implementing infectious diseases e-consults within an electronically integrated healthcare system, consultation volume increased. As compared with face-to-face consultations, e-consults were more often related to antimicrobial guidance and were requested by off-site providers. E-consults increased the breadth and volume of total consults.

Bringing mini-chalk talks to the bedside to enhance clinical teaching

Chalk talks - where the teacher is equipped solely with a writing utensil and a writing surface - have been used for centuries, yet little has been written about strategies for their use in medical education. Structured education proximal to patient encounters (during rounds, at the bedside, or in between patients in clinic) maximizes the opportunities for clinical learning. This paper presents a strategy to bring mini-chalk talks (MCTs) to the bedside as a practical way to provide relevant clinical teaching by visually framing teachable moments. Grounded in adult learning theory, MCTs leverage teaching scripts to facilitate discussion, involve learners at multiple levels, and embrace the increased retention associated with visual aids. These authors provide specific recommendations for the design and implementation of MCT sessions including what topics work well, how to prepare, and how to involve and engage the learners.

ABBREVIATIONS

ADHD: Attention Deficit Hyperactivity Disorder; MCT: Mini-chalk talks.

Evaluating an End-of-Life Curriculum in a Medical Residency Program

The ability to meet patient needs at the end of life is important. Boston University Residency Program in Medicine initiated a 1-week-long end-of-life curriculum that included a hospice care orientation, core articles, and home hospice visits. Evaluated was the impact of the rotation on participant knowledge and attitude. Knowledge was assessed by pretest and posttest questionnaires and compared with more senior resident controls, naïve to the curriculum. Attitudes toward issues relating to end-of-life care and subjective change in knowledge were assessed comparing subjects' retrospective preintervention and postintervention responses included in the postintervention questionnaire. Forty-five second-year participants completed both questionnaires. Participants demonstrated significant improvements in attitude and self-assessed knowledge of end-of-life care in 23 of 24 Likert-type scale questions. The end-of-life curriculum led to significant improvements in participant knowledge and attitudes about the conceptual and practical aspects of end-of-life care. The structure of the rotation should be reproducible in many locales.

The Ambulatory Diagnostic and Treatment Center: A Unique Model for Educating Medical Trainees and Providing Expedited Care

In this article, the authors reexamine the Ambulatory Diagnostic and Treatment Center (ADTC) model, which uniquely combines the education of trainees with the care of referred patients at one Veterans Affairs medical center. As an ambulatory clinic with an inpatient mind-set, the ADTC uses a series of closely spaced outpatient appointments that are longer than typical ambulatory visits, offering a VIP-level of evaluation with the patient-centered goal of expedited diagnosis and treatment. Faculty triage patients by weighing factors such as urgency, educational value, complexity, and instability of diseases in conjunction with the resources, availability, and appropriateness of other services within the medical center.The ADTC's unique focus on the education of trainees in comparison with other clinical rotations is evident in the ratio of learning to patient care. This intensive training environment expects postgraduate year 2 and 3 internal medicine residents and fourth-year medical students to read, reflect, and review literature daily. This mix of education and care delivery is ripe for reexploration in light of recent calls for curriculum reform amidst headlines exposing delays in veterans' access to care.A low-volume, high-intensity clinic like the ADTC can augment the clinical services provided by a busy primary care and subspecialty workforce without losing its emphasis on education. Other academic health centers can learn from this model and adapt its structure in settings where accountable care organizations and education meet.

Disruptive Innovation: Implementation of Electronic Consultations in a Veterans Affairs Health Care System

BACKGROUND

Electronic consultations (e-consults) offer rapid access to specialist input without the need for a patient visit. E-consult implementation began in 2011 at VA Boston Healthcare System (VABHS). By early 2013, e-consults were available for all clinical services. In this implementation, the requesting clinician selects the desired consultation within the electronic health record (EHR) ordering menu, which creates an electronic form that is pre-populated with patient demographic information and allows free-text entry of the reason for consult. This triggers a message to the requesting clinician and requested specialty, thereby enabling bidirectional clinician-clinician communication.

OBJECTIVE

The aim of this study is to examine the utilization of e-consults in a large Veterans Affairs (VA) health care system.

METHODS

Data from the electronic health record was used to measure frequency of e-consult use by provider type (physician or nurse practitioner (NP) and/or physician assistant), and by the requesting and responding specialty from January 2012 to December 2013. We conducted chart reviews for a purposive sample of e-consults and semi-structured interviews with a purposive sample of clinicians and hospital leaders to better characterize the process, challenges, and usability of e-consults.

RESULTS

A total of 7097 e-consults were identified, 1998 from 2012 and 5099 from 2013. More than one quarter (27.56%, 1956/7097) of the e-consult requests originated from VA facilities in New England other than VABHS and were excluded from subsequent analysis. Within the VABHS e-consults (72.44%, 5141/7097), variability in frequency and use of e-consults across provider types and specialties was found. A total of 64 NPs requested 2407 e-consults (median 12.5, range 1-415). In contrast, 448 physicians (including residents and fellows) requested 2349 e-consults (median 2, range 1-116). More than one third (37.35%, 1920/5141) of e-consults were sent from primary care to specialists. While most e-consults reflected a request for specialist input to a generalist's question in diagnosis or management in the ambulatory setting, we identified creative uses of e-consults, including requests for face-to-face appointments and documentation of pre-operative chart reviews; moreover, 7.00% (360/5141) of the e-consults originated from our sub-acute and chronic care inpatient units. In interviews, requesting providers reported high utility and usability. Specialists recognized the value of e-consults but expressed concerns about additional workload.

CONCLUSIONS

The e-consult mechanism is frequently utilized for its initial intended purpose. It has also been adopted for unexpected clinical and administrative uses, developing into a "disruptive innovation" and highlighting existing gaps in mechanisms for provider communication. Further investigation is needed to characterize optimal utilization of e-consults within specialty and the medical center, and what features of the e-consult program, other than volume, represent valid measures of access and quality care.

Limited adoption of current guidelines for clinical breast examination by primary care physician educators

BACKGROUND

In 2004, the CDC and the American Cancer Society (ACS) published performance guidelines recommending a validated method of clinical breast exams (CBE) using the vertical strips method (VSM) along with other key exam components. We examined the use of the VSM by academic medicine physicians and identified predictor variables for its adoption.

METHODS

Clinician educators in the Society of General Internal Medicine (SGIM) and physicians in the Society of Teachers of Family Medicine (STFM) were administered web-based surveys on CBE practices in 2009.

RESULTS

A total of 1,772 (42%) physicians responded. Only 40% of respondents reported using the VSM, compared with 53% using the circular search method. Variables and their odds ratios (ORs) associated with an increase adoption of the VSM were having a primary teaching hospital affiliation (OR 1.4 [1.1, 1.9]), having taken a course on breast health or breast cancer in the past 5 years (OR 1.5 [1.1, 2.0]), and having completed residency in the past 5 years (OR 2.3 [1.6, 3.4]) and/or 10-15 years (OR 1.6 [1.2, 2.2]) compared to more than 15 years. The extent of teaching responsibilities was not associated with adoption of the VSM.

CONCLUSIONS

A majority of physician responders highly involved in education of students and residents continue to practice methods of CBE that do not reflect the current guidelines. Faculty development and training on updated CBE practices may accelerate adoption of guideline-recommended care.

Human dimensions in bedside teaching: focus group discussions of teachers and learners

BACKGROUND

Clinical teaching has moved from the bedside to conference rooms; many reasons are described for this shift. Yet, essential clinical skills, professionalism, and humanistic patient interactions are best taught at the bedside.

PURPOSE

Clinical teaching has moved from the bedside to conference rooms; many reasons are described for this decline. This study explored perceptions of teachers and learners on the value of bedside teaching and the humanistic dimensions of bedside interactions that make it imperative to shift clinical teaching back to the bedside.

METHOD

Focus group methodology was used to explore teacher and learner opinions. Four teacher groups consisted of (a) Chief Residents, (b) Residency Program Directors, (c) skilled bedside teachers, and (d) a convenience group of other Department of Medicine faculty at Boston University School of Medicine. Six learner groups consisted 2 each of 3rd-year students, PGY1 medicine residents, and PGY2 medicine residents. Each discussion lasted 60 to 90 minutes. Sessions were audiotaped, transcribed, and analyzed using qualitative methods.

RESULTS

Teachers and learners shared several opinions on bedside teaching, particularly around humanistic aspects of bedside interactions. The key themes that emerged included (a) patient involvement in discussions, (b) teachers as role models of humanism, (c) preserving learner autonomy, (d) direct observation and feedback of learners at the bedside, (e) interactions with challenging patients, and (e) admitting limitations. Within these themes, participants noted some behaviors best avoided at the bedside.

CONCLUSIONS

Teachers and learners regard the bedside as a valuable venue in which to learn core values of medicine. They proposed many strategies to preserve these humanistic values and improve bedside teaching. These strategies are essential for true patient-centered care.

The path to physician leadership in community health centers: implications for training

BACKGROUND AND OBJECTIVES

Community health centers are facing a shortage of primary care physicians at a time when government plans have called for an expansion of community health center programs. To succeed with this expansion, community health centers require additional well-trained physician leadership. Our objective was to ascertain how medical directors obtain leadership skills in an attempt to identify the best methods and venues for providing future leadership training programs.

METHODS

Using recorded interviews and focus group data with community health center medical directors, we identified patterns and themes through cross-case content analysis to determine leadership training needs in underserved settings.

RESULTS

Medical directors often enter positions unprepared and can quickly become frustrated by an inability to make system improvements. Medical directors seek multiple ways to obtain the leadership skills necessary, including conferences, peer networking, mentorship, and formal degree training. Many directors express a desire for additional training, preferring flexibility in curriculum and hands-on components.

CONCLUSIONS

Additional leadership training opportunities for active and future medical directors are needed. Academic medical centers and other training sponsors should consider innovative ways to develop effective physician leadership to provide quality care to underserved communities.

Comparing a self-administered measure of empathy with observed behavior among medical students

PURPOSE

Studies show that measures of physician and medical students' empathy decline with clinical training. Presently, there are limited data relating self-reported measures to observed behavior. This study explores a self-reported measure and observed empathy in medical students.

METHOD

Students in the Class of 2009, at a university-based medical school, were surveyed at the end of their 2nd and 3rd year. Students completed the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a self-administered scale, and were evaluated for demonstrated empathic behavior during Objective Structured Clinical Examinations (OSCEs).

RESULTS

97.6% and 98.1% of eligible students participated in their 2nd and 3rd year, respectively. The overall correlation between the JSPE-S and OSCE empathy scores was 0.22, p < 0.0001. Students had higher self-reported JSPE-S scores in their 2nd year compared to their 3rd year (118.63 vs. 116.08, p < 0.0001), but had lower observed empathy scores (3.96 vs. 4.15, p < 0.0001).

CONCLUSIONS

Empathy measured by a self-administered scale decreased, whereas observed empathy increased among medical students with more medical training.

Improving bedside teaching: findings from a focus group study of learners

PURPOSE

Literature reviews indicate that the proportion of clinical educational time devoted to bedside teaching ranges from 8% to 19%. Previous studies regarding this paucity have not adequately examined the perspectives of learners. The authors explored learners' attitudes toward bedside teaching, perceptions of barriers, and strategies to increase its frequency and effectiveness, as well as whether learners' stages of training influenced their perspectives.

METHOD

Six focus group discussions with fourth-year medical students and first- or second-year internal medicine residents recruited from the Boston University School of Medicine and Residency Program in Internal Medicine were conducted between June 2004 and February 2005. Each 60- to 90-minute discussion was audiotaped, transcribed, and analyzed using qualitative methods.

RESULTS

Learners believed that bedside teaching is valuable for learning essential clinical skills. They believed it is underutilized and described many barriers to its use: lack of respect for the patient; time constraints; learner autonomy; faculty attitude, knowledge, and skill; and overreliance on technology. Learners suggested a variety of strategies to mitigate barriers: orienting and including the patient; addressing time constraints through flexibility, selectivity, and integration with work; providing learners with reassurance, reinforcing their autonomy, and incorporating them into the teaching process; faculty development; and advocating evidence-based physical diagnosis. Students focused on the physical diagnosis aspects of bedside teaching, whereas views of residents reflected their multifaceted roles as learners, teachers, and managers.

CONCLUSIONS

Bedside teaching is valuable but underutilized. Including the patient, collaborating with learners, faculty development, and promoting a supportive institutional culture can redress several barriers to bedside teaching.

Prolonged cerebellar ataxia: an unusual complication of hypoglycemia

A 51-year-old male with a history of insulin-dependent diabetes and polysubstance abuse presented after overdose on insulin. Soon after resuscitation, he displayed a severe ataxia in all 4 limbs and was unable to walk; all of which persisted for at least 5 days. Laboratory testing was unrevealing, including relatively normal brain magnetic resonance imaging. He had recovered full neurologic function 3 months after the event. This report describes a case of reversible cerebellar ataxia as a rare complication of severe hypoglycemia that may occur in patients with abnormal cerebellar glucose metabolism. Thus, this phenomenon should be included in the differential diagnosis of patients with a history of hypoglycemia who present with ataxia. In this context, the differential diagnosis of cerebellar ataxia is discussed, as is the proposed mechanism for hypoglycemia-induced cerebellar dysfunction.

Twelve tips for use of a white board in clinical teaching: reviving the chalk talk

Little has been written on the art of using a board in clinical teaching. The technological development of the white board appears to have coincided with that of the laptop computer and accompanying LCD projector, so that fewer and fewer teaching sessions appear to utilize the board as an efficient teaching tool. I have observed this most commonly among younger faculty who are most comfortable with technology and who may lack training and experience with a blank board. This paper offers suggestions on using the board in clinical teaching in order to enhance the educational process through better engagement of the learners.

Development of a Tool to Assess the Team Leadership Skills of Medical Residents

PURPOSE

To develop a tool to assess the team leadership skills of internal medicine residents.

METHOD

A 27-item pilot instrument developed by two authors was distributed to interns on ward and intensive care unit teams at the end of rotations from a single institution's internal medicine residency program. These items were factor analyzed and reduced to a seven-item resident leadership scale (RLS). Validity of the instrument was assessed by comparing the rating on the RLS to scores on a validated measure of teaching skills provided at the same time and by the program director's global rating of team leadership skill for each resident at the completion of data collection.

RESULTS

The three principal components from the factor analysis explained 82 percent of the variance. By introspection we reduced the scale to the final 7-item RLS that had a Cronbach alpha reliability estimate of 0.95. 490 ratings on 134 individual residents were available for analysis. The RLS scores correlated highly with both the validated measure of teaching skill and the program director's ratings.

CONCLUSION

The RLS has robust psychometric properties. It may provide a useful tool for a broader assessment of trainee skill if validated in other settings.

In the minority: black physicians in residency and their experiences

OBJECTIVE

To describe black residents' perceptions of the impact of race on medical training.

MATERIALS AND METHODS

Open-ended interviews were conducted of black physicians in postgraduate year 22 who had graduated from U.S. medical schools and were enrolled in residency programs at one medical school. Using Grounded Theory tenets of qualitative research, data was culled for common themes through repeated readings; later, participants commented on themes from earlier interviews.

RESULTS

Of 19 participants 10 were male, distributed evenly among medical and surgical fields. Four major themes emerged from the narratives: discrimination, differing expectations, social isolation and consequences. Participants' sense of being a highly visible minority permeated each theme. Overt discrimination was rare. Participants perceived blacks to be punished more harshly for the same transgression and expected to perform at lower levels than white counterparts. Participants' suspicion of racism as a motivation for individual and institutional behaviors was tempered by self-doubt. Social isolation from participants' white colleagues contrasted with connections experienced with black physicians, support staff and patients, and participants strongly desired black mentors. Consequences of these experiences varied greatly.

CONCLUSIONS

Black physicians face complex social and emotional challenges during postgraduate training. Creating supportive networks and raising awareness of these issues may improve training experiences for black physicians.

Morbidity and mortality conference: a survey of academic internal medicine departments

This study sought to determine the prevalence and characteristics of morbidity and mortality conferences (M&MCs) in U.S. internal medicine training programs. Two hundred ninety-five of 416 (71%) surveys were returned. Ninety percent of programs have an M&MC. Most meet monthly, have a designated leader, and entail case discussions of 3 or fewer patients. Cases are selected on the basis of unexpected bad outcomes, teaching value, and to a lesser extent, suspected medical error. Two thirds of the sites use M&MCs to meet administrative requirements for quality assurance. M&MC, while prevalent in internal medicine training programs, has a heterogeneity of focus. Hence, the goals and role of the conference, as judged by this survey, do not appear to be well defined and may warrant further clarification.

Whither bedside teaching? A focus-group study of clinical teachers

PURPOSE

Previous reports document diminishing time spent on bedside teaching, with a shift towards conference rooms and corridors. This study explored faculty's perceptions of the barriers to and their strategies for increasing and improving bedside teaching.

METHOD

Four focus groups consisting of (1) chief residents, (2) residency program directors, (3) skilled bedside teachers, and (4) a convenience group of other Department of Medicine faculty from the Boston University School of Medicine's affiliated hospitals were held in May 1998. Each session lasted 60-90 minutes. Sessions were audiotaped, transcribed, and analyzed using qualitative methods.

RESULTS

The most significant barriers reported were (1) declining bedside teaching skills; (2) the aura of bedside teaching, a belief that bedside teachers should possess an almost unattainable level of diagnostic skill that creates intense performance pressure; (3) that teaching is not valued; and (4) erosion of teaching ethic. Focus-group participants suggested the following strategies for addressing these barriers: improve bedside teaching skills through faculty training in clinical skills and teaching methods; reassure clinical faculty that they possess more than adequate bedside skills to educate trainees; establish a learning climate that allows teachers to admit their limitations; and address the undervaluing of teaching on a department level with adequate recognition and rewards for teaching efforts. Skilled teachers, in particular, stated that a bedside teaching ethic could be reestablished by emphasizing its importance and challenging learners to think clinically.

CONCLUSIONS

Bedside teaching is regarded as valuable. Some barriers may be overcome by setting realistic faculty expectations, providing incentives for teaching faculty, and establishing ongoing faculty development programs.

Medical residents' first clearly remembered experiences of giving bad news

CONTEXT

Communication of bad news to patients or families is a difficult task that requires skill and sensitivity. Little is known about doctors' formative experiences in giving bad news, what guidance they receive, or what lessons they learn in the process.

OBJECTIVE

To learn the circumstances in which medical residents first delivered bad news to patients or families, the nature of their experience, and their opinions about how best to develop the needed skills.

DESIGN

Confidential mailed survey.

SETTING AND SUBJECTS

All medicine house officers at 2 urban, university-based residency programs in Boston.

MAIN OUTCOME MEASURES

Details of medical residents' first clearly remembered experiences of giving bad news to a patient or family member; year in training; familiarity with the patient; information about any planning prior to, observation of, or discussion after their first experience; and the usefulness of such discussions. We also asked general questions about delivering bad news, such as how often this was done, as well as asking for opinions about actual and desired training.

RESULTS

One hundred twenty-nine of two hundred thirteen surveys (61%) were returned. Most (73%) trainees first delivered bad news while a medical student or intern. For this first experience, most (61%) knew the patient for just hours or days. Only 59% engaged in any planning for the encounter. An attending physician was present in 6 (5%) instances, and a more-senior trainee in 14 (11%) others. Sixty-five percent of subjects debriefed with at least 1 other person after the encounter, frequently with a lesser-trained physician or a member of their own family. Debriefing focused on the reaction of those who were given the bad news and the reaction of the trainee. When there were discussions with more-senior physicians, before or after the encounter, these were judged to be helpful approximately 80% of the time. Most subjects had given bad news between 5 and 20 times, yet 10% had never been observed doing so. Only 81 of 128 (63%) had ever observed an attending delivering bad news, but those who did found it helpful 96% of the time. On 7-point scales, subjects rated the importance of skills in delivering bad news highly, (mean 6.8), believed such skill can be improved (mean 6.6), and thought that more guidance should be offered to them during such activity (mean 5.8).

CONCLUSION

Medical students and residents frequently deliver bad news to patients and families. This responsibility begins early in training. In spite of their inexperience, many do not appear to receive adequate guidance or support during their earliest formative experiences.

The morbidity and mortality conference: the delicate nature of learning from error

The morbidity and mortality conference (M&MC) appears to have sprung from the efforts of physicians to improve practice through the examination of medical errors and bad outcomes. The modern M&MC has had limited examination (and almost none outside surgery and anesthesia), but may be straying from the precepts from which it evolved. Learning from one's errors is important, but confronting them is difficult and is particularly delicate when done in conference. If the effort is successful, it can serve as a model. If unsuccessful, it can instead convey the lesson that attempting to learn from error is at best unproductive and at worst unpleasant. Thus, the M&MC is a double-edged sword, and particular attention should be given to the way that it is conducted. The authors review the historical roots and current literature on the M&MC, discusses relevant literature on medical error, and offers a definition, guiding principles, and a set of guidelines for a modern internal medicine M&MC. The ideas are presented not as a blueprint, but rather to stimulate a debate on the merits of establishing a framework for a working model, in order to refocus on the tradition of self-analysis and critical thinking in a manner that is productive for all participants.

Co-teaching: a faculty development strategy

It has been stated that faculty development programmes which are closely linked to particular teaching contexts are most likely to be effective. Over the past 10 years we have developed a model of 'co-teaching' for faculty development which is based upon this premise and which can be applied to any clinical rotation. In this paper we describe our model, in which paired physicians focus on developing their teaching skills while sharing the clinical supervision of residents and medical students. Through iterative phases of teaching, debriefing and planning, co-teachers gain experience in analysing teaching encounters and develop skills in self-evaluation. Teaching occurs in the usual clinical settings such as attending (consultant) teaching rounds, clinic precepting, and case conferences. We discuss our model in the context of educational theory and related literature. We support our positive assessment of the co-teaching model through the precepts of collaborative inquiry and case study methodology. Vignettes, taken from the experiences of the authors, are used to demonstrate how the model is used to develop effective solutions to problems and to help in the maturation of one's skill as an educator. Successful implementation of the model is predicated on the development of a truly collaborative process between co-teachers. We share lessons we have learned from our experience of implementing the model in different clinical venues, such as the contrast between teaching on a hospital ward or in the clinic. This collaborative process has been well received by junior and senior faculty participants in our institution for more than a decade.

The effect of a teaching skills course on interns' and students' evaluations of their resident--teachers

PURPOSE

To determine the effect that a six-hour course on resident teaching and leadership skills had on residents' teaching evaluations.

METHOD

The authors analyzed six years of teaching evaluations of second- and third-year internal medicine residents at the University of Washington: three years before and three years after a resident teaching skills course was introduced in 1992. Interns and students rated their resident-teachers using a nine-question standardized clinical teaching assessment form (CTAF). Evaluations at baseline (the three years before the course) were compared with evaluations for the three years after the intervention.

RESULTS

The authors analyzed 3,946 evaluations of 235 second-year and 211 third-year residents. Despite already high baseline evaluations, mean ratings of the CTAF showed continuous and statistically significant improvement in each year after the introduction of the course (p < .001). There was no significant difference between evaluations from students and those from interns.

CONCLUSION

A six-hour teaching skills course significantly improved residents' teacher ratings. Residents are important teachers of interns and medical students and serve as their primary ward supervisors; therefore, sessions on teaching skills should be part of required curricula for all residency programs.

Use of advance directives by health care workers and their families

BACKGROUND

Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance of education in the decision to execute an AD, I did this study to determine the rate at which health care workers (a medically educated group) and their families execute ADs.

METHODS

All clinical staff at an urban tertiary care VA medical center were surveyed.

RESULTS

Of 730 surveys mailed, 553 (76%) were returned, and 18% of respondents executed an AD. Age was the only variable that predicted execution of an AD. End-of-life medical decision-making discussions with family members were reported frequently (with spouses 74%, parents 50%).

CONCLUSION

Health care workers do not appear to complete ADs at a rate any higher than the general population. Thus, education may be necessary, but alone it appears insufficient to increase use of ADs. Frequent family discussions occur among health care providers and their families. Such discussions may be an important outcome in their own right.

Improving medical residents' attitudes toward HIV-infected persons through training in an HIV staging and triage clinic

PURPOSE

To assess the effect of a weekly outpatient clinic for staging and triage of newly identified human-immunodeficiency-virus (HIV)-infected patients on medical residents' attitudes and knowledge regarding care of HIV-infected persons.

METHOD

Twenty-one second- and third-year medical residents who participated in the Diagnostic Evaluation Unit (DEU) of Boston City Hospital's Clinical AIDS Program from July 1991 through December 1991 were matched with a control group of 20 residents. Both groups of residents were asked to anonymously complete self-administered questionnaires before, immediately after, and three months following the DEU rotation. Responses were compared using repeated measures analysis of variance, two-tailed t-tests, and chi-square analysis.

RESULTS

Compared with the controls, the DEU residents showed an increased sense of feeling adequately trained to provide primary care to HIV-infected patients immediately after the rotation (p = .0002), which was sustained at the three-month follow-up (p < .001). Compared with the controls, the DEU residents also showed improved general attitudes toward treating persons with acquired immune deficiency syndrome, which persisted at the three-month follow-up, although these changes were not significant.

CONCLUSION

The experience in an HIV staging and triage clinic had a positive effect on the confidence and attitudes of the medical residents. Similar training experiences may increase the willingness and capacity of physicians to provide primary care to HIV-infected persons.

Soliciting feedback: on becoming an effective clinical teacher

The art of teaching is difficult to master. When teaching in small groups, as often happens in clinical medicine, there is an opportunity to find out what works by speaking directly with students. The information they provide can serve as an invaluable guide, permitting refinement of skill over time. There are, however, significant barriers to this process. The art lies in finding an approach that is comfortable for both parties. The authors refer to this activity as soliciting feedback. They offer guidelines for soliciting feedback as an aid to improving teaching efforts.

Urinary tract infections and estrogen use in older women

OBJECTIVE

To examine the relationship between exogenous estrogen use and risk of clinically diagnosed urinary tract infection (UTI) in older women.

DESIGN

A case-control study.

SETTING

Two hundred seventy-six general practices.

PATIENTS

Cases (n = 3,616) were women, age 50-69 years, with a first recorded UTI in the calendar years 1989 or 1990. Controls (n = 19,162) were matched for age and practice.

MAIN OUTCOME MEASURE

Clinical diagnosis of UTI.

RESULTS

Women using estrogens for greater than or equal to 1 year had an increased risk of being diagnosed with a UTI compared to non-users, crude odds ratio (OR) 1.9 (95% CI 1.5-2.2). All of this excess risk was observed in women with intact uteri, OR 2.1 (CI 1.7-2.7). Hysterectomized women had no increased risk, OR 1.1 (CI 0.8-1.5). Controlling for diabetes, neurologic deficit, atrophic vaginitis, incontinence, and age did not affect the observed associations.

CONCLUSION

Estrogen use is associated with an increased risk of UTI in older women with intact uteri but not in hysterectomized women. This observed differential effect on women with or without uteri may be explained by prescribing biases between these two groups of women, but we lack any evidence to support this conclusion over several alternative possibilities.

Fellowship training in academic general internal medicine: a curriculum survey

OBJECTIVE

To determine whether current fellowships in general internal medicine (FGIM) meet the perceived needs and objectives of physicians entering careers in academic internal medicine.

DESIGN

A modified Delphi method yielded the 18 curricular elements included in the mailed survey. Participants outlined both actual and ideal fellowship experiences by rating the degree of emphasis of each curricular element on a Likert scale. Respondents then prioritized elements by rank-ordering them on perceived importance. Current job descriptions and opinions on related issues in FGIM were collected.

PARTICIPANTS

Potential fellows, current fellows, and recent graduates were surveyed. Individuals were identified through the Society of General Internal Medicine associates' mailing list and solicitation of program directors. Nonfellow associates served as the proxy group for potential fellows.

MEASUREMENTS AND MAIN RESULTS

579 surveys were mailed; 348 (60%) responses were received, of which 288 (50%) were suitable for analysis. Of all respondents, 38% were current fellows and 40% were recent graduates. When asked to prioritize educational needs during fellowship training, respondents ranked research methodology, ambulatory medicine, critical review of the literature, epidemiology, biostatistics, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curriculum as the top ten. Only minor deviations in rank order were found between graduates and nongraduates. Mean Likert scale scores for degree of emphasis of each curricular element in graduates' actual fellowships were compared with mean scores for graduates' ideal fellowship descriptions. High-priority elements that were perceived as adequately emphasized included research methodology, critical analysis of the literature, epidemiology, and biostatistics. High-priority elements that were perceived as inadequately emphasized included ambulatory medicine, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curricula.

CONCLUSIONS

FGIM largely meet the expectations of their fellows for preparation for research responsibilities. However, several curricular elements concerned with preparation for future clinical and teaching responsibilities are perceived by graduates as underemphasized. These areas deserve increased emphasis during fellowship training to better prepare fellows for their future roles in academic general internal medicine.