How to Use and Report on p-values

The use of the p-value in quantitative research, particularly its threshold of "P < 0.05" for determining "statistical significance," has long been a cornerstone of statistical analysis in research. However, this standard has been increasingly scrutinized for its potential to mislead findings, especially when the practical significance, the number of comparisons, or the suitability of statistical tests are not properly considered. In response to controversy around use of p-values, the American Statistical Association published a statement in 2016 that challenged the research community to abandon the term "statistically significant". This stance has been echoed by leading scientific journals to urge a significant reduction or complete elimination in the reliance on p-values when reporting results. To provide guidance to researchers in health professions education, this paper provides a succinct overview of the ongoing debate regarding the use of p-values and the definition of p-values. It reflects on the controversy by highlighting the common pitfalls associated with p-value interpretation and usage, such as misinterpretation, overemphasis, and false dichotomization between "significant" and "non-significant" results. This paper also outlines specific recommendations for the effective use of p-values in statistical reporting including the importance of reporting effect sizes, confidence intervals, the null hypothesis, and conducting sensitivity analyses for appropriate interpretation. These considerations aim to guide researchers toward a more nuanced and informative use of p-values.

Implementation and Analysis of a 5-Year Online Esophageal Motility Curriculum for Gastroenterology Fellows

BACKGROUND

Motility disorders are frequently encountered in gastroenterology (GI) practice, yet a national structured training curriculum for GI fellows in motility disorders is lacking. Since GI fellowships vary considerably in opportunities for specialized esophageal motility (EM) training, novel educational technology may be leveraged to provide standardized EM curriculum to train GI fellows in esophageal manometry.

METHODS

GI fellows participated in an online EM learning program at a single academic center from 2017 to 2022. Fellows answered case-based questions and were provided with evidence-based, corrective feedback related to core EM learning objectives. The primary outcome was change in knowledge and comfort in interpretation and clinical application of EM studies.

RESULTS

Sixty-nine fellows actively participated in the online EM curriculum. 65 fellows completed a pre-curriculum test, and 54 fellows completed a post-curriculum test. There was a cumulative improvement between pre-curriculum test and post-curriculum test scores from 70 to 87%, respectively (p < 0.001). Fellows had a mean improvement of 19% in questions as they progressed through the curriculum. Prior to enrolling in the EM course, 26% of fellows felt comfortable in interpreting EM studies compared to 54% of fellows after completion of the program (p < 0.001).

CONCLUSION

An online, technology-based curriculum was effective in educating GI fellows on core competencies of EM. Fellows demonstrated improvement in proficiency of clinically important EM studies and increased comfort in interpreting EM studies. Further studies are needed to evaluate the use of technology-based learning to widely disseminate a structured training curriculum in EM, particularly in training programs without a motility presence.

Assessing the Impact of COVID-19 on IBD Outcomes Among Vulnerable Patient Populations in a Large Metropolitan Center

BACKGROUND

With the onset of COVID-19, there were rapid changes in healthcare delivery as remote access became the norm. The aim of this study was to determine the impact of changes in healthcare delivery during the COVID-19 pandemic on patients with inflammatory bowel disease (IBD), in both well-resourced and vulnerable populations.

METHODS

Using a mixed methods, observational study design, patients receiving IBD care at a university or a safety-net hospital were identified by the electronic health record. Patient demographics, IBD history, and disease activity were acquired from the electronic health record. IBD-related outcomes were compared from the onset of the pandemic in the United States until December 2020 (COVID-19 pandemic year 1) and compared with outcomes in the previous year. A subset of participants provided their perspective on how changes in healthcare delivery and financial stability impacted their IBD through a standardized questionnaire and semi-structured interview.

RESULTS

Data from a total of 1449 participants were captured, 1324 at the tertiary care university hospital and 125 at the safety-net hospital. During COVID-19, there was a decrease in healthcare utilization at both sites. Race/ethnicity and primary language were not associated with IBD-related hospitalizations or admissions. Patients that were employed and those with insurance had a higher number of IBD-related emergency department visits at both the university and safety-net hospitals (P = .03 and P = .01, respectively). Patients who did not speak English were more likely to report challenges using technology with telehealth and difficulty contacting IBD providers.

CONCLUSIONS

For IBD populations, during COVID-19, in both hospital settings, emergency department visits, hospitalizations, outpatient surgery, and clinic visits were reduced compared with the year prior. Patients with lower socioeconomic status and limited English proficiency reported facing more challenges with changes to healthcare delivery, healthcare access, and conveying changes in IBD activity. These results highlight the need for payors and providers to specifically attend to those populations most susceptible to these systemic and lasting changes in care delivery and promote greater equity in healthcare.

Senior trainee as endoscopy teacher: impact on trainee learning and attending experience

Objective

Training in how to effectively teach endoscopy is not included in most gastroenterology (GI) training programme curricula, yet many gastroenterologists are expected to teach endoscopy in their careers. Near-peer teaching could help senior GI trainees learn how to teach endoscopy and have benefits for junior trainees. We performed a qualitative study of a peer teaching initiative where senior trainees taught endoscopy to junior trainees under attending supervision.

Design

We observed endoscopy sessions where the senior trainee taught a junior trainee under attending supervision, and then conducted individual interviews with the senior trainee teacher, junior trainee learner and attending to characterise affordances and barriers to learning. We performed thematic analysis on anonymised interview transcripts.

Results

10 observations and 30 interviews were completed. Junior trainees reported senior trainees more approachable than attendings and explained concepts in more understandable ways. Senior trainees reported the teaching role improved skill at both teaching and performing endoscopy. Attendings reported positive impressions of the experience for senior trainees, and generally positive impressions with some reservations of the experience for junior trainees. A few barriers to learning were reported, but they were generally perceived as being outweighed by affordances. An area for improvement was setting clear expectations for senior trainee and attending roles before the session.

Conclusion

Near-peer endoscopy teaching was feasible and provided perceived affordances for junior and senior trainees alike, with few barriers. Incorporating formal training in teaching endoscopy into GI training programme curricula may produce both better endoscopists and better endoscopy teachers.

Development of eConsult reflective learning tools for healthcare providers: a pragmatic mixed methods approach

BACKGROUND

Electronic consultation (eConsult) programs are crucial components of modern healthcare that facilitate communication between primary care providers (PCPs) and specialists. eConsults between PCPs and specialists. They also provide a unique opportunity to use real-world patient scenarios for reflective learning as part of professional development. However, tools that guide and document learning from eConsults are limited. The purpose of this study was to develop and pilot two eConsult reflective learning tools (RLTs), one for PCPs and one for specialists, for those participating in eConsults.

METHODS

We performed a four-phase pragmatic mixed methods study recruiting PCPs and specialists from two public health systems located in two countries: eConsult BASE in Canada and San Francisco Health Network eConsult in the United States. In phase 1, subject matter experts developed preliminary RLTs for PCPs and specialists. During phase 2, a Delphi survey among 20 PCPs and 16 specialists led to consensus on items for each RLT. In phase 3, we conducted cognitive interviews with three PCPs and five specialists as they applied the RLTs on previously completed consults. In phase 4, we piloted the RLTs with eConsult users.

RESULTS

The RLTs were perceived to elicit critical reflection among participants regarding their knowledge and practice habits and could be used for quality improvement and continuing professional development.

CONCLUSION

PCPs and specialists alike perceived that eConsult systems provided opportunities for self-directed learning wherein they were motivated to investigate topics further through the course of eConsult exchanges. We recommend the RLTs be subject to further evaluation through implementation studies at other sites.

Pre-clerkship Teaching and Learning in the Virtual Learning Environment: Lessons Learned and Future Directions

In response to the COVID-19 pandemic, we developed and implemented a theory-informed process to adapt a comprehensive pre-clerkship medical school curriculum to run in the virtual learning environment utilizing sociocultural learning theory and cognitive load theory. Of 124 student respondents, 45% rated virtual learning as very or extremely effective, and 49% as moderately effective. Positive aspects of virtual learning included effectiveness of chat moderators, displaying pronouns on Zoom, active learning technology, and captioning and transcription. Negative aspects included access to technology and feeling isolated from community. Overall course ratings, examination performance, and work hours did not differ pre- and post-implementation.

Inflammatory bowel disease type influences development of elevated liver enzymes

Background and Aim

Up to a third of patients with inflammatory bowel disease (IBD) have elevated liver enzymes (ELE). We evaluated the incidence, predictors, and outcomes associated with ELE in a diverse and vulnerable IBD cohort.

Methods

We retrospectively evaluated 336 IBD patients receiving care at the San Francisco safety net gastroenterology clinics between June 1996 and December 2019. Baseline characteristics were captured at first visit, then patients were followed until last clinic activity or death. Testing and etiology, pattern of ELE defined as transient (<1 month) or persistent (≥1 month), were assessed. Multivariate modeling evaluated predictors of ELE at baseline, new ELE at follow-up, and pattern of ELE.

Results

Baseline median age was 40.3 years, 62% male, 46% White (13% Black, 19% Asian, and 18% Latino), and 59% had ulcerative colitis (UC). Among those without known liver disease (n = 14), 51.6% (166 of 322; 52 at baseline, 114 during follow-up) had ELE. In multivariate logistic regression, 5-aminosalicylic acid use (odds ratio [OR] 2.2, 95% confidence interval [CI]: 1.07-4.4, P = 0.03) and higher body mass index (OR 1.08, 95% CI: 1.02-1.14, P = 0.01) were associated with baseline ELE. In multivariate Cox regression, UC (vs. Crohn's disease [CD]) had a 34% lower risk of developing new ELE during follow-up (hazard ratio [HR] 0.66, 95% CI: 0.46-0.95, P = 0.02). Mortality rate was higher for patients with ELE (0% normal vs 2.3% transient ELE vs 6.5% persistent ELE, P < 0.001).

Conclusion

ELE is prevalent in IBD, especially in CD, and associated with higher rates of mortality. Identification and management of ELE particularly when persistent are important to IBD outcomes.

Can I Ask a Question About URiM Awards That I Don't Know the Answer to? Designing an Award for Underrepresented Medical Education Researchers

Meaningful Equity, Diversity, and Inclusion (EDI) efforts may be stymied by concerns about whether proposed initiatives are performative or tokenistic. The purpose of this project was to analyze discussions by the Research in Medical Education (RIME) Program Planning committee about how best to recognize and support underrepresented in medicine (URiM) researchers in medical education to generate lessons learned that might inform local, national, and international actions to implement meaningful EDI initiatives. Ten RIME Program Planning Committee members and administrative staff participated in a focus group held virtually in August 2021. Focus group questions elicited opinions about "if and how" to establish a URiM research award. The focus group was recorded, transcribed, and thematically analyzed. Recognition of privilege, including who has it and who doesn't, underpinned the focus group discussion, which revolved around 2 themes: (1) tensions between optics and semantics, and (2) potential unintended consequences of trying to level the medical education playing field. The overarching storyline threaded throughout the focus group discussion was intentionality. Focus group participants sought to avoid performativity by creating an award that would be meaningful to recipients and to career gatekeepers such as department chairs and promotion and tenure committees. Ultimately, participants decided to create an award that focused on exemplary Equity, Diversity, and Inclusion (EDI) scholarship, which was eventually named the "RIME URiM Research Award." Difficult but productive conversations about EDI initiatives are necessary to advance underrepresented in medicine (URiM) scholarship. This transparent commentary may trigger further critical conversations.

Exploring the relationship between emotion and cognitive load types during patient handovers

Cognitive Load Theory has emerged as an important approach to improving instruction in the health professions workplace, including patient handovers. At the same time, there is growing recognition that emotion influences learning through numerous cognitive processes including motivation, attention, working memory, and long-term memory. This study explores how emotion influences the cognitive load experienced by trainees performing patient handovers. From January to March 2019, 693 (38.7%) of 1807 residents and fellows from a 24-hospital health system in New York city completed a survey after performing a handover. Participants rated their emotional state and cognitive load. The survey included questions about features of the learner, task, and instructional environment. The authors used factor analysis to identify the core dimensions of emotion. Regression analyses explored the relationship between the emotion factors and cognitive load types. Two emotion dimensions were identified representing invigoration and tranquility. In regression analyses, higher levels of invigoration, tranquility, and their interaction were independently associated with lower intrinsic load and extraneous load. The interaction of invigoration and tranquility predicted lower germane load. The addition of the emotion variables to multivariate models including other predictors of cognitive load types significantly increased the amount of variance explained. The study provides a model for measuring emotions in workplace learning. Because emotion appears to have a significant influence on cognitive load types, instructional designers should consider strategies that help trainees regulate emotion in order to reduce cognitive load and improve learning and performance.

Evidence for validity for the Cognitive Load Inventory for Handoffs

CONTEXT

Patient handovers remain a significant patient safety challenge. Cognitive load theory (CLT) can be used to identify the cognitive mechanisms for handover errors. The ability to measure cognitive load types during handovers could drive the development of more effective curricula and protocols. No such measure currently exists.

METHODS

The authors developed the Cognitive Load Inventory for Handoffs (CLIH) using a multi-step process, including expert interviews to enhance content validity and talk-alouds to optimise response process validity. The final version contained 28 items. From January to March 2019, we administered a cross-sectional survey to 1807 residents and fellows from a large health care system in the USA. Participants completed the CLIH following a handover. Exploratory factor analysis of data from one-third of respondents identified high-performing items; confirmatory factor analysis of data from the remaining sample assessed model fit. Model fit was evaluated using the comparative fit index (CFI) (>0.90), Tucker-Lewis index (TFI) (>0.80), standardised root mean square residual (SRMR) (<0.08) and root mean square of error of approximation (RMSEA) (<0.08).

RESULTS

Participants included 693 trainees (38.4%) (231 in the exploratory study and 462 in the confirmatory study). Eleven items were removed during exploratory factor analysis. Confirmatory factor analysis of the 16 remaining items (five for intrinsic load, seven for extraneous load and four for germane load) supported a three-factor model and met criteria for good model fit: the CFI was 0.95, TFI was 0.93, RMSEA was 0.074 and SRMR was 0.07. The factor structure was comparable for gender and role. Intrinsic, extraneous and germane load scales had high internal consistency. With one exception, scale scores were associated, as hypothesised, with postgraduate level and clinical setting.

CONCLUSIONS

The CLIH measures three types of cognitive load during patient handovers. Evidencefor validity is provided for the CLIH's content, response process, internal structure and association with other variables. This instrument can be used to determine the relative drivers of cognitive load during handovers in order to optimize handover instruction and protocols.

How do attending physicians describe cognitive overload among their workplace learners?

OBJECTIVES

Cognitive load theory (CLT) focuses on the limited bandwidth of working memory. Core to CLT is the concept of cognitive overload, which occurs when working memory demands exceed working memory capacity, and learning and performance suffer. Within health professions education (HPE), workplace learning settings are very complex, placing learners at high risk of cognitive overload. Although continuous monitoring of physiologic parameters can indicate states of high cognitive load, how to practically identify cognitively overloaded learners within everyday workplace settings is not well understood. We sought to characterise how attending physicians described their perceiving of cognitive overload among learners in two different workplace settings: the gastrointestinal endoscopy suite and the intensive care unit.

METHODS

We performed a secondary qualitative analysis of transcripts of interviews with workplace teachers that had been carried out during two previous studies. These studies had addressed different objectives but both were informed by CLT. Each included questions that prompted participants to reflect on how they perceived cognitive overload to manifest among learners in the workplace. To investigate the phenomenon of cognitive overload, we developed a new codebook and performed content analysis.

RESULTS

We analysed 42 interview transcripts (22 endoscopists, 12 hospitalists, eight intensivists). Participants described four behaviours they had witnessed among learners they thought were cognitively overloaded: poor performance on workplace tasks; non-verbal physical manifestations (including posture, eye and body movements and autonomic functions); verbal utterances (words and sounds), and interpersonal interactions with team members. Endoscopists often described individually oriented examples, whereas intensivists and hospitalists tended to frame examples within an interpersonal context.

CONCLUSIONS

We identified four overarching ways in which HPE workplace teachers perceived learners as appearing to be cognitively overloaded. Workplace teachers and learners should be mindful of and watch for these signs, which may signal states of cognitive overload. Earlier recognition of cognitive overload may facilitate timely action to reduce cognitive overload and promote learning.

The Hiker's Guide to the RIME Supplement: Choosing Directions in Research

In this Commentary, the authors seek to build on prior RIME commentaries by considering how researchers transition from worldviews, focal lengths, and research goals to research directions and methodological choices. The authors use the analogy of a hiker to illustrate how different researchers studying a similar phenomenon can choose among different research directions, which lead down different paths and offer different perspectives on a problem. Following the hiker analogy, the authors use the "Research Compass" to categorize the 15 research papers included in the 2020 Research in Medical Education supplement according to their research aim and corresponding methodological approach. The authors then discuss implications of the relative balance of these study types within this supplement and within health professions education research at large, emphasizing the critical importance of studying a topic from multiple vantage points to construct a richer and more nuanced understanding of health professions education challenges. The authors conclude by recognizing the challenges we face in the current era of COVID-19 and by calling health professions education researchers and practitioners to continue our collective efforts to improve learner education and patient care, as we together navigate the unfamiliar terrain of the present day.

Using Cognitive Load Theory to Improve Teaching in the Clinical Workplace

INTRODUCTION

Cognitive load theory (CLT) views working memory as the primary bottleneck for learning, as it is limited in both capacity and retention. CLT delineates three types of activities that impose on working memory: intrinsic load, germane load, and extraneous load. These three constructs have practical ramifications for direct teaching, learning environments, and curricular design. CLT could help educators across health professions improve quality of teaching, especially in demanding and unpredictable workplace environments. However, few educational resources exist to familiarize clinical workplace educators with CLT.

METHODS

We developed a 2-hour workshop focused on CLT's core concepts and practical applications, targeted at health professions' workplace educators. It featured large-group, small-group, and individual reflective activities. An end-of-workshop survey was administered, and a follow-up survey was sent to participants 2 months after the workshop.

RESULTS

A total of 134 educators attended the first two offerings of the workshop in two different states. Participants considered CLT as relevant to a variety of workplace teaching settings and activities. Participants' self-assessed familiarity with CLT on a 0-100 scale increased from a mean of 36 (SD = 26) before the workshop to 59 (SD = 17) after the workshop. At follow-up, participants scored an average of 85% on content knowledge questions. Approximately half of respondents to the follow-up survey stated they had made or planned to make specific changes to their workplace teaching leveraging tenets of CLT.

DISCUSSION

The workshop conveyed CLT concepts and primed participants to independently craft CLT-based interventions for their own teaching practices.

Learning Challenges, Teaching Strategies, and Cognitive Load: Insights From the Experience of Seasoned Endoscopy Teachers

PURPOSE

Learners of medical procedures must develop, refine, and apply schemas for both cognitive and psychomotor constructs, which may strain working memory capacity. Procedures with limitations in visual and tactile information may add risk of cognitive overload. The authors sought to elucidate how experienced procedural teachers perceived learners' challenges and their own teaching strategies in the exemplar setting of gastrointestinal endoscopy.

METHOD

The authors interviewed 22 experienced endoscopy teachers in the United States, Canada, and the Netherlands between May 2016 and March 2019 and performed thematic analysis using template analysis method. Interviews addressed learner challenges and teaching strategies from the teacher participants' perspectives. Cognitive load theory informed data interpretation and analysis.

RESULTS

Participants described taking steps to "diagnose" trainee ability and identify struggling trainees. They described learning challenges related to trainees (performance over mastery goal orientation, low self-efficacy, lack of awareness), tasks (psychomotor challenges, mental model development, tactile understanding), teachers (teacher-trainee relationship, inadequate teaching, teaching variability), and settings (internal/external distractions, systems issues). Participants described employing strategies that could match intrinsic load to learners' levels (teaching along developmental continuum, motor instruction, technical assistance/takeover), minimize extraneous load (optimize environment, systems solutions, emotional support, define expectations), and optimize germane load (promote mastery, teach schemas, stop and focus).

CONCLUSIONS

Participants provided insight into possible challenges while learning complex medical procedures with limitations in sensory channels, as well as teaching strategies that may address these challenges at individual and systems levels. Using cognitive load theory, the authors provide recommendations for procedural teachers.

Best Practices in Teaching Endoscopy Based on a Delphi Survey of Gastroenterology Program Directors and Experts in Endoscopy Education

BACKGROUND AND AIMS

Teaching endoscopy is a key objective of gastroenterology (GI) fellowship programs but the best approach is not known. We sought to characterize which teaching competencies experts considered most critical for endoscopy education.

METHODS

We developed and refined 18 endoscopy teaching competencies based on literature review, personal experience, and interviews with experts. We invited GI fellowship program directors and endoscopy education experts to participate in a Delphi process to rate each proposed competency as essential, important but not essential, or not important using a 70% agreement threshold for consensus. Thirty-four GI fellowship program directors and 2 experts in endoscopy education participated (n = 36).

RESULTS

Most survey participants were male (61.8%), associate professors (55.9%), and had performed at least a quarter of procedures with fellows (80.6%). Survey response rates were 94% (34 of 36) for round 1 and 91% (31 of 34) for round 2 (overall 31 of 36; 86.1%). After 2 rounds we achieved the predefined consensus level for most competencies. Fourteen of 18 competencies (77.8%) reached consensus after round 2: 10 (55.6%) were deemed essential and 4 (22.2%) were deemed important but not essential. Essential competencies included the following: discusses patient history and plans for procedure with trainee (100%), assumes control of procedure when trainee is unable to progress or if patient safety concerns arise (100%), maintains attention throughout the case (96.8%), and discusses the next steps in management for the patient (96.8%).

CONCLUSIONS

In a national Delphi survey of endoscopy education experts, we identified 10 essential endoscopy teaching competencies. These can be used to frame faculty development and standardize GI fellowship programs to promote high-quality endoscopy education.

Trainee perception of cognitive load during observed faculty staff teaching of procedural skills

OBJECTIVES

Although teachers impact learners' cognitive load, how specific teaching activities affect intrinsic, germane and extraneous load during procedural skills training is unknown. We sought to characterise teaching activities used in the exemplar procedural setting of colonoscopy, and to explore how they were enacted and how learners perceived them as affecting intrinsic, germane and extraneous cognitive load.

METHODS

We observed 10 colonoscopies performed by eight different gastroenterology fellows and supervised by 10 different attending physicians at two hospitals, and recorded the teaching activities observed, as well as details of when they were used and how they were enacted. After the colonoscopy, each fellow completed the Cognitive Load Inventory for Colonoscopy to quantify intrinsic, germane and extraneous load. We then interviewed each fellow to determine how he or she perceived teaching as affecting cognitive load. Qualitative data were subjected to content analysis. Instances of germane load-promoting activities were correlated with measured germane load.

RESULTS

We observed 515 instances of teaching activities. The intensity of teaching varied substantially, ranging from 0.7 to 3.3 activities per minute, as did the pattern of teaching activities used by different attending physicians. Little teaching occurred immediately before or after a procedure. Fellows usually perceived teaching as affecting cognitive load in ways that promoted learning, particularly by reducing intrinsic load and increasing germane load. Fellows strongly perceived that the provision of autonomy promoted germane load. Conversely, fellows perceived that excessive teaching increased extraneous load. Instances of germane load-promoting teaching activities correlated moderately with measured germane load.

CONCLUSIONS

Teaching in the exemplar procedural setting of colonoscopy affected learners' cognitive load in mostly beneficial ways, yet even 'good' teaching activities had detrimental effects when used excessively. Teachers of procedures should consider learner experience, task complexity and environmental factors to modulate the modality, content and intensity of teaching to promote balanced cognitive load and learning. Teaching more reservedly during the procedure and taking advantage of pre- and post-procedure opportunities may help.

Cognitive load theory for training health professionals in the workplace: A BEME review of studies among diverse professions: BEME Guide No. 53

AIM

Cognitive load theory (CLT) is of increasing interest to health professions education researchers. CLT has intuitive applicability to workplace settings, yet how CLT should inform teaching, learning, and research in health professions workplaces is unclear.

METHOD

To map the existing literature, we performed a scoping review of studies involving cognitive load, mental effort and/or mental workload in professional workplace settings within and outside of the health professions. We included actual and simulated workplaces and workplace tasks.

RESULT

Searching eight databases, we identified 4571 citations, of which 116 met inclusion criteria. Studies were most often quantitative. Methods to measure cognitive load included psychometric, physiologic, and secondary task approaches. Few covariates of cognitive load or performance were studied. Overall cognitive load and intrinsic load were consistently negatively associated with the level of experience and performance. Studies consistently found distractions and other aspects of workplace environments as contributing to extraneous load. Studies outside the health professions documented similar findings to those within the health professions, supporting relevance of CLT to workplace learning.

CONCLUSION

The authors discuss implications for workplace teaching, curricular design, learning environment, and metacognition. To advance workplace learning, the authors suggest future CLT research should address higher-level questions and integrate other learning frameworks.

What Makes a Good Endoscopic Teacher: A Qualitative Analysis

OBJECTIVE

Teaching learners to perform endoscopic procedures is challenging, yet effective endoscopy teaching practices are not well-described in the literature, and prior studies have focused on perspectives of supervising physicians rather than learners. We sought to characterize, from the perspective of endoscopy learners, endoscopic teaching behaviors perceived as beneficial and detrimental to learning using qualitative methods.

DESIGN

This is a prospective qualitative content analysis. Gastroenterology fellows from 2 tertiary care centers anonymously provided feedback regarding supervising physicians' teaching behaviors during endoscopic training between March 2016 and December 2016. Preprinted cards were completed at the conclusion of procedures to document behaviors that fellows perceived as enhancing or hampering their learning. Two investigators performed content analysis of written comments; each identified behavior was assigned positive or negative valence.

SETTING

Mount Sinai Hospital in New York, New York and University of California San Francisco in San Francisco, California. Both institutions are academic tertiary care centers.

PARTICIPANTS

A total of 19 gastroenterology fellows at 2 training institutions participated.

RESULTS

A total of 239 teaching behaviors were identified by 19 fellows who worked with 31 supervising physicians; 29 unique behaviors were identified and organized into 7 themes: teaching, learning environment, autonomy, communication, coaching, feedback, and professionalism. Of all, 185 (77.4%) behaviors were reported as beneficial, and 54 (22.6%) as detrimental to the learning experience. Behaviors related to teaching were most often perceived as beneficial, while behaviors related to professionalism and communication were most often perceived as detrimental to learning.

CONCLUSIONS

Specific teaching behaviors may help or hinder learning of endoscopic skills. These behaviors may be useful for efforts related to teaching evaluation, faculty development, and direct teaching.

Race/ethnicity is an independent risk factor for autoimmune hepatitis among the San Francisco underserved

Although autoimmune hepatitis (AIH) is more common in women and affects people of all races/ethnicities, there is currently limited information regarding the relationship between race/ethnicity and AIH, especially in the context of underserved populations. We aim to evaluate the relationship between race/ethnicity and AIH and better characterize its clinical features among different racial groups. We conducted a 15-year retrospective analysis, from January 2002 to June 2017, of patients seen at Zuckerberg San Francisco General Hospital (ZSFG). Sixty-three AIH patients and 2049 non-AIH controls were eligible for the study. The main predictor of interest was race/ethnicity, and the main outcome of interest was AIH diagnosis; other secondary measures recorded include clinical features such as ALT, bilirubin, and biopsy fibrosis at presentation. In a multivariable model adjusting for age and sex, we found that black (OR 9.6, 95% CI 1.8-178), Latino (OR 25.0, 95% CI 5.3-448), and Asian/Pacific Islander (API) (OR 10.8, 95% CI 2.2-196) race/ethnicity were associated with increased odds of an AIH diagnosis compared to the white reference group. Among people of colour with AIH, there were no significant differences in baseline ALT (p = .45), total bilirubin at presentation (p = .06), fibrosis at presentation (p = .74), and hospitalization (p = .27). Race/ethnicity is an independent risk factor for AIH. The clinical features of AIH did not differ significantly among black, Latino, and API patients.

Gastroenterologist and primary care perspectives on a post-endoscopy discharge policy: impact on clinic wait times, provider satisfaction and provider workload

Background

To reduce unnecessary ambulatory gastroenterology (GI) visits and increase access to GI care, San Francisco Health Network gastroenterologists and primary care providers implemented guidelines in 2013 that discharged certain patients back to primary care after endoscopy with formal written recommendations. This study assesses the longer-term impact of this policy on GI clinic access, workflow, and provider satisfaction.

Methods

An email-based survey assessed gastroenterologist and primary care provider (PCP) opinions about the discharge process. Administrative data and chart review were used to assess clinic access, intervention fidelity, and re-referral rates.

Results

102/299 (34%) of PCPs and 5/7 (71%) of gastroenterologists responded to the survey. 74% of PCPs and 100% of gastroenterologists were satisfied or very satisfied with the discharge process. 80% of gastroenterologists believed the discharge process decreased their workload, while 53.5% of primary care providers believed it increased their workload. 6.7% of patients discharged to primary care in 2013 had re-referrals to GI. Wait time for the third-next-available new outpatient GI clinic appointment had previously decreased from 158 days (2012, pre-intervention) to 74 days (2013, post-intervention). In 2015, wait time was 19 days (p < 0.001 for 2012 vs. 2015).

Conclusions

Primary care providers and gastroenterologists are satisfied with an intervention to discharge patients from gastroenterology to primary care after certain endoscopic procedures, although this conclusion is limited by a relatively low PCP survey response rate. Discharging appropriate patients using consensus criteria from the gastroenterology clinic was instrumental in sustainably reducing clinic wait times with low re-referral rates.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2819-6) contains supplementary material, which is available to authorized users.

Learner, Patient, and Supervisor Features Are Associated With Different Types of Cognitive Load During Procedural Skills Training: Implications for Teaching and Instructional Design

PURPOSE

Cognitive load theory, focusing on limits of the working memory, is relevant to medical education; however, factors associated with cognitive load during procedural skills training are not well characterized. The authors sought to determine how features of learners, patients/tasks, settings, and supervisors were associated with three types of cognitive load among learners performing a specific procedure, colonoscopy, to identify implications for procedural teaching.

METHOD

Data were collected through an electronically administered survey sent to 1,061 U.S. gastroenterology fellows during the 2014-2015 academic year; 477 (45.0%) participated. Participants completed the survey immediately following a colonoscopy. Using multivariable linear regression analyses, the authors identified sets of features associated with intrinsic, extraneous, and germane loads.

RESULTS

Features associated with intrinsic load included learners (prior experience and year in training negatively associated, fatigue positively associated) and patient/tasks (procedural complexity positively associated, better patient tolerance negatively associated). Features associated with extraneous load included learners (fatigue positively associated), setting (queue order positively associated), and supervisors (supervisor engagement and confidence negatively associated). Only one feature, supervisor engagement, was (positively) associated with germane load.

CONCLUSIONS

These data support practical recommendations for teaching procedural skills through the lens of cognitive load theory. To optimize intrinsic load, level of experience and competence of learners should be balanced with procedural complexity; part-task approaches and scaffolding may be beneficial. To reduce extraneous load, teachers should remain engaged, and factors within the procedural setting that may interfere with learning should be minimized. To optimize germane load, teachers should remain engaged.

Assessment of quality indicators among nurse practitioners performing upper endoscopy

BACKGROUND AND STUDY AIMS

 Limited international data have shown that non-physicians can safely perform upper endoscopy, but no such study has been performed in the United States. Our aim was to assess the quality of outpatient upper endoscopies performed by nurse practitioners (NPs).

PATIENTS AND METHODS

 Retrospective chart review of upper endoscopies performed by 3 NPs between 2010 and 2013 was performed. Comparisons among all NPs performing upper endoscopy and assessment of individual NP performance over time with respect to quality indicators were performed.

RESULTS

Three NPs performed 333 upper endoscopies (distribution of 166, 44, and 123, respectively). Of the cases, 98.2 %s were successfully completed to the second portion of the duodenum. In most cases, photo-documentation of required anatomical landmarks was performed: GE junction (84.2 %), GE junction in retroflexed view (84.2 %), antrum (82.1 %) and duodenum (80.9 %). Photo-documentation improved with increasing experience. NPs appropriately performed biopsies for specific medical conditions: 10/11 (90.9 %) gastric ulcers were biopsied and 63/66 (95.5) of patients with iron deficiency had duodenal biopsies performed for celiac disease. A physician endoscopist was required during the procedure 22.5 % of the time. Important parameters such as documenting informed consent (100 %) and documenting a discharge plan (99.4 %) in the procedure reports were overwhelming present. There was a single adverse event during the study period.

CONCLUSION

 In the first US study of NPs performing upper endoscopy, they were able to perform high-quality and safe upper endoscopies. These findings support incorporation of non-physicians alongside physicians to help meet the growing demand for endoscopic services across the United States.

Urgent colonoscopy in patients with lower GI bleeding: a systematic review and meta-analysis

BACKGROUND AND AIMS

Lower GI bleeding (LGIB) is a common cause of morbidity and mortality. Colonoscopy is indicated in all hospitalized patients with LGIB, yet the time frame for performing colonoscopy remains unclear. Prior studies of outcomes in urgent versus elective colonoscopy have yielded conflicting results and were often underpowered. Our study objective was to compare several outcomes between urgent and elective colonoscopy in patients hospitalized for LGIB.

METHODS

Systematic review and meta-analysis were performed on studies that compared urgent and elective colonoscopy in patients with LGIB. Pooled rates were calculated for specific outcomes, and rate ratios were determined for selected comparison groups.

RESULTS

Twelve studies met inclusion criteria, with a total sample size of 10,172 patients in the urgent colonoscopy arm and 14,224 patients in the elective colonoscopy arm. Urgent colonoscopy was associated with increased use of endoscopic therapeutic intervention (RR, 1.70; 95% CI, 1.08-2.67). There were no significant differences in bleeding source localization (RR, 1.08; 95% CI, .92-1.25), adverse event rates (RR, 1.05; 95% CI, .65-1.71), rebleeding rates (RR, 1.14; 95% CI, .74-1.78), transfusion requirement (RR, 1.02; 95% CI, .73-1.41), or mortality (RR, 1.17; 95% CI, .45-3.02).

CONCLUSIONS

Urgent colonoscopy appears to be safe and well tolerated, but there is no clear evidence that it alters important clinical outcomes.

Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange

BACKGROUND

Effective communication between referring and specialty providers is key to optimizing patient safety. Communication was assessed in an electronic referral system by review of referrals to a public urban health care system's gastroenterology clinic that were not scheduled for appointments.

METHODS

All electronic referrals to a publicly funded, urban health care system's adult gastroenterology clinic from November 1, 2009, to November 30, 2010, were reviewed that did not result in scheduling of appointments. An assessment was made of whether in-person visits were unnecessary by preconsultation exchange or whether the referrals remained unscheduled for other reasons. For the latter group, reasons why the referrals remained unscheduled were examined, and medical records were reviewed for actual patient harm when sufficient information was present in the chart or for potential harm when no further information about the referral complaint was available.

RESULTS

Eighty-six (32%) of 266 not-scheduled referrals were resolved via preconsultation exchange. For another 96 (36%), patients were not ultimately considered to require appointments or were scheduled via other routes. Nine patients received unplanned care while awaiting scheduling decisions, 5 of whom had harm that was related to referral complaints, although scheduling of appointments may not have avoided this harm. Of 75 patients for whom further information was not available about the referral complaints, most were not seen back in primary care, and 55 (73%) had potential for major harm.

CONCLUSION

Few adverse outcomes in electronic referrals not scheduled for in-person gastroenterology visits were found, and none were clearly due to communication lapses in the referral process. Contributors to the potential for harm in referrals that were unintentionally left unscheduled included discontinuity of care and lack of patient or provider follow-up.

Performance of a cognitive load inventory during simulated handoffs: Evidence for validity

BACKGROUND

Advancing patient safety during handoffs remains a public health priority. The application of cognitive load theory offers promise, but is currently limited by the inability to measure cognitive load types.

OBJECTIVE

To develop and collect validity evidence for a revised self-report inventory that measures cognitive load types during a handoff.

METHODS

Based on prior published work, input from experts in cognitive load theory and handoffs, and a think-aloud exercise with residents, a revised Cognitive Load Inventory for Handoffs was developed. The Cognitive Load Inventory for Handoffs has items for intrinsic, extraneous, and germane load. Students who were second- and sixth-year students recruited from a Dutch medical school participated in four simulated handoffs (two simple and two complex cases). At the end of each handoff, study participants completed the Cognitive Load Inventory for Handoffs, Paas' Cognitive Load Scale, and one global rating item for intrinsic load, extraneous load, and germane load, respectively. Factor and correlational analyses were performed to collect evidence for validity.

RESULTS

Confirmatory factor analysis yielded a single factor that combined intrinsic and germane loads. The extraneous load items performed poorly and were removed from the model. The score from the combined intrinsic and germane load items associated, as predicted by cognitive load theory, with a commonly used measure of overall cognitive load (Pearson's r = 0.83, p < 0.001), case complexity (beta = 0.74, p < 0.001), level of experience (beta = -0.96, p < 0.001), and handoff accuracy (r = -0.34, p < 0.001).

CONCLUSION

These results offer encouragement that intrinsic load during handoffs may be measured via a self-report measure. Additional work is required to develop an adequate measure of extraneous load.

Measuring cognitive load during procedural skills training with colonoscopy as an exemplar

OBJECTIVES

Few studies have investigated cognitive factors affecting learning of procedural skills in medical education. Cognitive load theory, which focuses on working memory, is highly relevant, but methods for measuring cognitive load during procedural training are not well understood. Using colonoscopy as an exemplar, we used cognitive load theory to develop a self-report instrument to measure three types of cognitive load (intrinsic, extraneous and germane load) and to provide evidence for instrument validity.

METHODS

We developed the instrument (the Cognitive Load Inventory for Colonoscopy [CLIC]) using a multi-step process. It included 19 items measuring three types of cognitive load, three global rating items and demographics. We then conducted a cross-sectional survey that was administered electronically to 1061 gastroenterology trainees in the USA. Participants completed the CLIC following a colonoscopy. The two study phases (exploratory and confirmatory) each lasted for 10 weeks during the 2014-2015 academic year. Exploratory factor analysis determined the most parsimonious factor structure; confirmatory factor analysis assessed model fit. Composite measures of intrinsic, extraneous and germane load were compared across years of training and with global rating items.

RESULTS

A total of 477 (45.0%) invitees participated (116 in the exploratory study and 361 in the confirmatory study) in 154 (95.1%) training programmes. Demographics were similar to national data from the USA. The most parsimonious factor structure included three factors reflecting the three types of cognitive load. Confirmatory factor analysis verified that a three-factor model was the best fit. Intrinsic, extraneous and germane load items had high internal consistency (Cronbach's alpha 0.90, 0.87 and 0.96, respectively) and correlated as expected with year in training and global assessment of cognitive load.

CONCLUSIONS

The CLIC measures three types of cognitive load during colonoscopy training. Evidence of validity is provided. Although CLIC items relate to colonoscopy, the development process we detail can be used to adapt the instrument for use in other learning settings in medical education.

Prevalence and predictors of patient no-shows to outpatient endoscopic procedures scheduled with anesthesia

BACKGROUND

Demand for endoscopic procedures scheduled with anesthesia is increasing and no-show to appointments carries significant patient health and financial impact, yet little is known about predictors of no-show.

METHODS

We performed a 16-month retrospective observational cohort study of patients scheduled for outpatient endoscopy with anesthesia at a county hospital serving the safety-net healthcare system of San Francisco. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show.

RESULTS

In total, 511 patients underwent endoscopy with anesthesia during the study period. Twenty-seven percent of patients failed to attend an appointment and were considered "no-show". In multivariate analysis, higher no-show rates were associated with patients with a prior history of no-show (odds ratio [OR] 6.4; 95% confidence interval [CI], 2.4- 17.5), those with active substance abuse within the past year (OR 2.2; 95% CI 1.4-3.6), those with heavy prescription opioids/benzodiazepines use (OR 1.6; 95% CI 1.0-2.6) and longer wait-times (OR 1.05; 95% CI 1.00-1.09). Inversely associated with patient no-show were active employment (OR 0.38; 95% CI 0.18-0.81), patients who attended a pre-operative appointment with an anesthesiologist (OR 0.52; CI 0.32-0.85), and those undergoing an advanced endoscopic procedure (OR 0.43; 95% CI 0.19-0.94).

CONCLUSION

In a safety-net healthcare population, behavioral and social determinants of health, including missed appointments, active substance abuse, homelessness, and unemployment are associated with no-shows to endoscopy with anesthesia.

Applying cognitive load theory to medical education: construct and measurement challenges

None

Liver transplantation for hepatocellular carcinoma: analysis of factors predicting outcome in 1074 patients in OPTN Region 5

Previous studies on loco-regional therapy (LRT) and alpha-fetoprotein (AFP) in predicting outcome after liver transplant (LT) for hepatocellular carcinoma (HCC) have shown inconsistent results. We analyzed the OPTN database in Region 5 from January 2004 to January 2009 and performed univariate and multivariate analysis of 11 pre-transplant recipient and donor variables in 1074 patients with HCC meeting Milan criteria to detect association with post-LT tumor recurrence or mortality. Mean waitlist time was 438 d. The 1- and 5-yr post-LT survival was 91.1% and 71.1%, respectively. In multivariate analysis, AFP before LT was the only predictor of HCC recurrence. The association between AFP and HCC recurrence was observed only in the subgroup receiving LRT but not in the subgroup without LRT. Predictors of mortality in multivariate analysis were HCC recurrence, Donor Risk Index, last AFP before LT, and MELD score. AFP before LT was the strongest predictor of post-transplant HCC recurrence or death in multivariate analysis. In conclusion, in Region 5 with prolonged waitlist time, high AFP was the only pre-transplant variable predicting post-transplant tumor recurrence and mortality for HCC meeting Milan criteria. Our results also supported the importance of the effects of LRT on AFP in predicting prognosis.

Preconsultation exchange in the United States: use, awareness, and attitudes

OBJECTIVES

Demand for specialty care exceeds supply in many healthcare systems in the United States. Preconsultation exchange has the potential to increase access to specialty care, and increase its timeliness and efficiency, by triaging need and urgency and streamlining the previsit workup. We sought to characterize attitudes toward, use of, and concerns regarding preconsultation exchange among US internists.

STUDY DESIGN

Prospective cross-sectional survey.

METHODS

We administered a Web-based survey to a large national panel of US internists maintained by the American College of Physicians.

RESULTS

Response rate was 55% (N=451) with minimal differences between responders and nonresponders. Of responders, only 13% were initially familiar with the term "preconsultation exchange," but once defined, 28% were classified as frequent users, 40% as occasional users, and 32% as rare/never users. Internists used preconsultation exchange to: guide the prespecialty visit workup (78%), answer clinical questions without a patient visit to the specialist (71%), triage referral urgency (67%), and transfer referrals to a more appropriate specialty (47%). Responders supported multiple benefits of preconsultation exchange, but also reported concerns regarding reimbursement, liability, physicians taking personal responsibility for patient care, and inadequate exchange of clinical information. Compared with primary care physicians, specialists recognized more benefits of preconsultation exchange, but also expressed more concerns. The majority of responders reported increased willingness to use preconsultation exchange if specific remedies were applied.

CONCLUSIONS

Most US internists participate in preconsultation exchange and agree with its potential benefits. However, important concerns and barriers exist. Methods to reduce barriers to preconsultation exchange should be identified.

Increasing access to specialty care: patient discharges from a gastroenterology clinic

OBJECTIVES

Access to specialty care among safety net patients in the United States is inadequate. Discharging appropriate patients to routine primary care follow-up may improve specialty care access. We sought to identify, by consensus, patients who could safely be discharged from a gastroenterology (GI) clinic, and to evaluate the impact of the discharges on GI clinic work flow.

STUDY DESIGN

Pre- and post intervention.

METHODS

We developed and implemented a modified Delphi process. Gastroenterologists and primary care providers (PCPs) rated their comfort (using 5-point Likert scales) with discharging patients immediately post endoscopy for 24 clinical scenarios, assuming formal recommendations were communicated to the PCP. We examined the impact of implementing these criteria on clinic wait times and on the ratio of new to follow-up visits.

RESULTS

All gastroenterologists (100%; 7 of 7) and 71.0% of PCPs (130 of 183) participated. Consensus was achieved for 13 of the 24 clinical scenarios for which discharge criteria were developed. Post intervention, 403 patients were discharged from the GI clinic, compared with 0 patients in the same 4 calendar months pre-intervention. The ratio of new to follow-up appointments increased from 0.9:1 to 1:1 (P = .05). Median wait time for the third next available appointment at GI clinics decreased from 158 days to 74 days (P = .0001).

CONCLUSIONS

Discharging patients from specialty care back to primary care with consensus standards is one method to improve access to specialty care. Understanding the concerns of all stakeholders is necessary to refine and disseminate this process to other specialties and healthcare systems to ensure timely access to specialty services for all patients.

Assessment of delivery methods used in the informed consent process at a safety-net hospital

BACKGROUND

Informed consent is legally and ethically required before a patient undergoes an endoscopic procedure, yet current literature suggests that patient comprehension of key components of informed consent is poor.

OBJECTIVE

To evaluate specific aspects of and patient satisfaction with the informed consent process in patients who attended an endoscopy education class versus gastroenterology clinic.

DESIGN

Prospective survey that examined all components of the informed consent process.

SETTING

Safety-net hospital.

PATIENTS

Outpatients undergoing endoscopy.

INTERVENTION

Endoscopy education class versus gastroenterology clinic.

MAIN OUTCOME MEASUREMENTS

Patient recall of the components of and satisfaction with the informed consent process.

RESULTS

A total of 301 patients completed the survey, 52.0% of whom attended and were consented in an endoscopy education class. Patients who attended an endoscopy education class reported that a greater number of individual components of the informed consent process were explained to them as compared with patients who were consented in clinic. In multivariate analysis, patients who attended an education class were more likely to recall having had the alternatives (odds ratio [OR] 4.8; 95% confidence interval [CI], 2.0-11.8), details of the procedure (OR 3.0; 95% CI, 1.3-6.8), and what to expect after the procedure (OR 3.0; 95% CI, 1.5-5.6) explained to them by a provider. These patients were more likely to know they could refuse the procedure (OR 4.1; 95% CI, 1.0-16.8), compared with patients consented in the gastroenterology clinic.

LIMITATIONS

Non-randomized trial.

CONCLUSION

Patients from a diverse, urban population who attended a multilingual endoscopy education class reported having more elements of the informed consent process explained to them compared with patients who were consented in gastroenterology clinic.

Meta-analysis: antibiotic therapy for small intestinal bacterial overgrowth

BACKGROUND

Small intestinal bacterial overgrowth (SIBO) is an under-recognised diagnosis with important clinical implications when untreated. However, the optimal treatment regimen remains unclear.

AIM

To perform a systematic review and meta-analysis comparing the clinical effectiveness of antibiotic therapies in the treatment of symptomatic patients with documented SIBO.

METHODS

Four databases were searched to identify clinical trials comparing effectiveness of: (i) different antibiotics, (ii) different doses of the same antibiotic and (iii) antibiotics compared with placebo. Data were independently extracted according to predetermined inclusion and exclusion criteria. Study quality was independently assessed. The primary outcome was normalisation of post-treatment breath testing. The secondary outcome was post-treatment clinical response.

RESULTS

Of 1356 articles identified, 10 met inclusion criteria. Rifaximin was the most commonly studied antibiotic (eight studies) with overall breath test normalisation rate of 49.5% (95% confidence interval, CI 44.0-55.1) (44.0%-55.1%) then (46.7%-55.5%), then (4.6%-17.8%). Antibiotic efficacy varied by antibiotic regimen and dose. Antibiotics were more effective than placebo, with a combined breath test normalisation rate of 51.1% (95% CI 46.7-55.5) for antibiotics compared with 9.8% (95% CI 4.6-17.8) for placebo. Meta-analysis of four studies favoured antibiotics over placebo for breath test normalisation with an odds ratio of 2.55 (95% CI 1.29-5.04). Clinical response was heterogeneously evaluated among six studies, but tended to correlate with breath test normalisation.

CONCLUSIONS

Antibiotics appear to be more effective than placebo for breath test normalisation in patients with symptoms attributable to SIBO, and breath test normalisation may correlate with clinical response. Studies were limited by modest quality, small sample size and heterogeneous design. Additional higher quality clinical trials of SIBO therapy are warranted.

A brief, low-cost intervention improves the quality of ambulatory gastroenterology consultation notes

BACKGROUND

Effective communication between primary care providers and specialty providers is important to facilitate high-quality specialty care. Few studies have assessed the quality of communication from specialist to primary care providers or implemented interventions to improve quality. We developed a brief, low-cost intervention designed to improve the quality of ambulatory gastroenterology consultation notes written by fellows and nurse practitioners in our urban health care system.

METHODS

Six physicians (3 specialists and 3 primary care providers) scored pre- and postintervention notes using an objective quality assessment instrument that had excellent inter-rater reliability. They were blinded to note date, author, and pre/postintervention status. The primary outcome was improvement in Composite Quality Score, an objective, comprehensive assessment of quality. Secondary outcomes included improvements in 3 specific domains, and Global Quality Score (a subjective measure of quality).

RESULTS

Two hundred pre- and 200 postintervention notes written by 6 fellows and 2 nurse practitioners were included. Composite Quality Score improved from 3.74 (of 5) to 4.09 (P <.001 in adjusted analysis). All secondary outcomes improved in adjusted analyses as well. The largest increase was seen in Communication Domain (22% increase). Fellow-written notes had higher scores than nurse practitioner-written notes, but nurse practitioner-written notes improved to a greater degree.

CONCLUSION

A brief, low-cost intervention significantly improved the quality of ambulatory gastroenterology consultation notes written by fellows and nurse practitioners. Communication between primary care providers and specialists is an important area for further study.