Breaking Down Silos Between Medical Education and Health Systems: Creating an Integrated Multilevel Data Model to Advance the Systems-Based Practice Competency

ABSTRACT

The complexity of improving health in the United States and the rising call for outcomes-based physician training present unique challenges and opportunities for both graduate medical education (GME) and health systems. GME programs have been particularly challenged to implement systems-based practice (SBP) as a core physician competency and educational outcome. Disparate definitions and educational approaches to SBP, as well as limited understanding of the complex interactions between GME trainees, programs, and their health system settings, contribute to current suboptimal educational outcomes elated to SBP. To advance SBP competence at individual, program, and institutional levels, the authors present the rationale for an integrated multilevel systems approach to assess and evaluate SBP, propose a conceptual multilevel data model that integrates health system and educational SBP performance, and explore the opportunities and challenges of using multilevel data to promote an empirically driven approach to residency education. The development, study, and adoption of multilevel analytic approaches to GME are imperative to the successful operationalization of SBP and thereby imperative to GME's social accountability in meeting societal needs for improved health. The authors call for the continued collaboration of national leaders toward producing integrated and multilevel datasets that link health systems and their GME-sponsoring institutions to evolve SBP.

The Reliability of Graduate Medical Education Quality of Care Clinical Performance Measures

BACKGROUND

Graduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied.

OBJECTIVE

To examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care.

METHODS

From 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated.

RESULTS

The highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable.

CONCLUSIONS

GME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.

Evolving the Systems-Based Practice Competency in Graduate Medical Education to Meet Patient Needs in the 21st-Century Health Care System

Medical education is increasingly recognizing the importance of the systems-based practice (SBP) competency in the emerging 21st-century U.S. health care landscape. In the wake of data documenting insufficiencies in care delivery, notably in patient safety and health care disparities, the Accreditation Council for Graduate Medical Education created the SBP competency to address gaps in health outcomes and facilitate the education of trainees to better meet the needs of patients. Despite the introduction of SBP over 20 years ago, efforts to realize its potential have been incomplete and fragmented. Several challenges exist, including difficulty in operationalizing and evaluating SBP in current clinical learning environments. This inconsistent evolution of SBP has compromised the professional development of physicians who are increasingly expected to advance systems of care and actively contribute to improving patient outcomes, patient and care team experience, and costs of care. The authors prioritize 5 areas of focus necessary to further evolve SBP: comprehensive systems-based learning content, a professional development continuum, teaching and assessment methods, clinical learning environments in which SBP is learned and practiced, and professional identity as systems citizens. Accelerating the evolution of SBP in these 5 focus areas will require health system leaders and educators to embrace complexity with a systems thinking mindset, use coproduction between sponsoring health systems and education programs, create new roles to drive alignment of system and educational goals, and use design thinking to propel improvement efforts. The evolution of SBP is essential to cultivate the next generation of collaboratively effective, systems-minded professionals and improve patient outcomes.

A framework to understand the needs of the medical students of the future

Purpose: Medical education is undergoing curricular reform driven by internal needs and external pressures. Concurrently, medical students are changing. More diverse student bodies, particularly those from underrepresented minorities, bring different skill sets, needs and priorities to their medical school education. Here we present their voices.Methods: In order to explore the stories, needs and motivations of future physicians, we conducted a small-scale study of students from diverse backgrounds in US medical schools. Our interviews revealed two core themes about medical school: (1) that medical school is an extreme physical and emotional challenge for all students, and (2) that medical school education consists of multiple conflicting goals. Combining the two themes provides a descriptive topology of student's motivations and strategies for getting through medical school. Using this framework, we deconstruct the experience of medical school to reveal the gaps and misalignments between the traditional system of medical education and what medical students want, expect and need to be successful.Conclusions: We discuss the implications of our research and this framework for curricula and the learning environment with a particular focus on (1) cooperative learning and social interdependence theory and (2) an expanded understanding of diversity and the needs of under-represented students.

Twelve Tips for Students in Longitudinal Integrated Clerkships

This article was migrated. The article was marked as recommended. Longitudinal integrated clerkships (LICs) are a curricular structure for medical clerkships grounded in continuity across learning environments and experiences. There has yet to be a peer-reviewed article directly advising students in LIC programs. Twelve tips were created based on a comprehensive literature review of LICs and supported by the cumulative experience of the authors. They are ordered in four sequential groups: The first three tips discuss the importance of the relationships that are built between students and their patients (Tip 1), preceptors (Tip 2), and peers (Tip 3). Next we cover health systems, and offer advice on how students can integrate their learning (Tip 4), use technology to their advantage (Tip 5), and practice systems thinking (Tip 6). We then discuss the educational benefits when students take an active role in patient care (Tip 7), their own learning (Tip 8), and the feedback process (Tip 9). Finally, we cover the importance of self-care (Tip 10), reflection (Tip 11) and patience (Tip 12) during a LIC. These tips are designed to help students understand the pedagogical theory that underpins LICs, take an active role in their education, and maximize learning and wellness during their clerkship.

Diffusion of innovation and longitudinal integrated clerkships: Results of the clerkship directors in internal medicine annual survey

PURPOSE

Longitudinal integrated clerkships (LICs) are innovative educational models that emphasize medical student continuity with patients, preceptors, peers, and health systems. We characterize LIC growth in the US and interpret the growth using Rogers' Diffusion of Innovation Theory.

METHODS

In 2015, we surveyed 123 US allopathic medical schools affiliated with Clerkship Directors in Internal Medicine (CDIM). The organization's annual survey was supplemented with questions aimed to quantify the number of current and planned LICs and to determine the intended purpose of starting LICs.

RESULTS

Of the 94 (out of 123 possible) schools which were responding, 35 (37%) have at least one LIC of six months or greater; of these 20 are year-long. Nineteen schools are engaged in planning a new LIC or increasing the number of students in an LIC. At least 45 (48%) responding schools will have LICs in future years. Respondents report implementing LICs to foster continuity of care, support patient-centeredness, advance inter-professional education, and address workforce shortages.

CONCLUSIONS

The number of LICs is increasing across the US. We considered the data through the lens of Diffusion of Innovation Theory, speculated that LIC growth has reached "critical mass," and considered why the LIC innovation may be self-sustaining.

Diffusion of innovation and longitudinal integrated clerkships: Results of the clerkship directors in internal medicine annual survey

PURPOSE

Longitudinal integrated clerkships (LICs) are innovative educational models that emphasize medical student continuity with patients, preceptors, peers, and health systems. We characterize LIC growth in the US and interpret the growth using Rogers' Diffusion of Innovation Theory.

METHODS

In 2015, we surveyed 123 US allopathic medical schools affiliated with Clerkship Directors in Internal Medicine (CDIM). The organization's annual survey was supplemented with questions aimed to quantify the number of current and planned LICs and to determine the intended purpose of starting LICs.

RESULTS

Of the 94 (out of 123 possible) schools which were responding, 35 (37%) have at least one LIC of six months or greater; of these 20 are year-long. Nineteen schools are engaged in planning a new LIC or increasing the number of students in an LIC. At least 45 (48%) responding schools will have LICs in future years. Respondents report implementing LICs to foster continuity of care, support patient-centeredness, advance inter-professional education, and address workforce shortages.

CONCLUSIONS

The number of LICs is increasing across the US. We considered the data through the lens of Diffusion of Innovation Theory, speculated that LIC growth has reached "critical mass," and considered why the LIC innovation may be self-sustaining.

Texting Brief Podcasts to Deliver Faculty Development to Community-Based Preceptors in Longitudinal Integrated Clerkships

INTRODUCTION

Longitudinal integrated clerkships (LICs) are an increasingly popular clerkship model that relies heavily on community-based preceptors. The availability of an engaged and prepared community-based faculty is crucial to the success of these programs. Teachers in these programs are often geographically separate from medical school campuses, are engaged in busy practices, and have limited time to devote to faculty development activities.

METHODS

We created a series of five brief faculty development podcasts directed towards community-based teachers in LICs from three US medical schools. Topics included encouraging continuity, bedside teaching, encouraging student ownership of patients, communicating and managing patient results between clinic days, and choosing the right patients for continuity. The podcasts were sent via a grouped text message just prior to preceptors' morning commute time. Pre- and postsurveys assessed the acceptability and effectiveness of the podcasts.

RESULTS

Among the 33 postintervention survey responders, 27 (81.8%) listened to at least three podcasts, 21 (63.6%) found them moderately or very helpful, 23 (69.7%) perceived that the podcasts altered their teaching style, 23 (69.7%) would likely or highly likely listen to further podcasts, and 18 (54.5%) would likely or highly likely recommend the podcasts to colleagues.

DISCUSSION

In a cohort of multispecialty faculty teaching in LICs, educational podcasts were well received and perceived by preceptors to impact their teaching style. Texting these podcasts to other community-based preceptors may offer an effective strategy for providing faculty development to busy clinicians.

Perceptions of evaluation in longitudinal versus traditional clerkships

OBJECTIVES

Methods for evaluating student performance in clerkships traditionally suffer shortcomings, partly as a result of clerkship structure. The purpose of this study was to compare preceptors' and students' perceptions of student evaluation in block clerkships and longitudinal integrated clerkships (LICs).

METHODS

From 2007 to 2009, preceptors who taught on both block clerkships and an LIC were surveyed on their perceptions of clerkship evaluation. Year 3 students were surveyed on their perceptions of clerkship evaluation at the year end. Responses from preceptors who completed both block clerkship and LIC surveys were compared using paired-samples t-test; student responses were compared using independent-samples t-test.

RESULTS

Overall, 66% (67/102) of block clerkship and 75% (77/102) of LIC preceptors responded; 44% of preceptors (45/102) completed both block and LIC surveys. In total, 62% (68/110) of block clerkship and 83% (19/23) of LIC students responded. Both preceptors and students favoured evaluation in the LIC on three factors (p ≤ 0.01): validity of evaluation process, quality of clinical skill evaluation, and willingness to provide constructive feedback.

CONCLUSIONS

Preceptors and students perceived evaluation in an LIC more favourably than evaluation on block clerkships. For educators working to improve student evaluation, further examination of the LIC structure and evaluation processes that seem to enhance both formative assessment and summative evaluation may be useful to improve the quality of evaluation and feedback.

Development of a longitudinal integrated clerkship at an academic medical center

In 2005, medical educators at the University of California, San Francisco (UCSF), began developing the Parnassus Integrated Student Clinical Experiences (PISCES) program, a year-long longitudinal integrated clerkship at its academic medical center. The principles guiding this new clerkship were continuity with faculty preceptors, patients, and peers; a developmentally progressive curriculum with an emphasis on interdisciplinary teaching; and exposure to undiagnosed illness in acute and chronic care settings. Innovative elements included quarterly student evaluation sessions with all preceptors together, peer-to-peer evaluation, and oversight advising with an assigned faculty member. PISCES launched with eight medical students for the 2007/2008 academic year and expanded to 15 students for 2008/2009. Compared to UCSF's traditional core clerkships, evaluations from PISCES indicated significantly higher student satisfaction with faculty teaching, formal didactics, direct observation of clinical skills, and feedback. Student performance on discipline-specific examinations and United States Medical Licensing Examination step 2 CK was equivalent to and on standardized patient examinations was slightly superior to that of traditional peers. Participants' career interests ranged from primary care to surgical subspecialties. These results demonstrate that a longitudinal integrated clerkship can be implemented successfully at a tertiary care academic medical center.

Faculty verbal evaluations reveal strategies used to promote medical student performance

BACKGROUND

Preceptors rarely follow medical students' developing clinical performance over time and across disciplines. This study analyzes preceptors' descriptions of longitudinal integrated clerkship (LIC) students' clinical development and their identification of strategies to guide students' progress.

METHODS

We used a common evaluation framework, reporter-interpreter-manager-educator, to guide multidisciplinary LIC preceptors' discussions of students' progress. We conducted thematic analysis of transcripts from preceptors' (seven longitudinal ambulatory preceptors per student) quarterly group discussions of 15 students' performance over one year.

RESULTS

All students' clinical development progressed, although most experienced obstacles. Lack of structure in the history and physical exam commonly obstructed progression. Preceptors used templates for data gathering, and modeling or experiences in the inpatient setting to provide time and solidify structure. To advance students' knowledge acquisition, many preceptors identified focused learning topics with their students; to promote application of knowledge, preceptors used reasoning strategies to teach the steps involved in synthesizing clinical data. Preceptors shared accountability for helping students advance as the LIC allowed them to follow students' response to teaching strategies.

DISCUSSION

These results depict preceptors' perceptions of LIC students' developmental continuum and illustrate how multidisciplinary preceptors can use a common evaluation framework to identify strategies to improve performance and follow students' performance longitudinally.

Advancing geriatrics education: an efficient faculty development program for academic hospitalists increases geriatric teaching

BACKGROUND

Hospitalists care for an increasing number of older patients. As teachers, they are uniquely positioned to teach geriatric skills to residents. Faculty development programs focused on geriatrics teaching skills are often expensive and time-intensive, and may not enhance trainee learning.

OBJECTIVES

To evaluate a train-the-trainer (TTT) model designed to equip hospitalists with knowledge and skills to teach geriatric topics to residents in a time-constrained, resource-limited environment.

DESIGN

Cross-sectional survey.

SETTING

Academic tertiary hospital.

INTERVENTION

A 10-hour geriatric curriculum, the Reynolds Program for Advancing Geriatrics Education (PAGE), cotaught by geriatricians and hospitalists at preexisting noon conferences over 1 year that consisted of exportable teaching modules.

MEASUREMENTS

Session leaders' and faculty participants' satisfaction, hospitalist geriatrics teaching self-efficacy, residents' self-report of frequency of geriatric teaching received, and frequency of geriatric skill use.

RESULTS

The curriculum was highly rated by session leaders and hospitalist faculty. Hospitalists perceived improvement in geriatric teaching skills, indicating (1: "unlikely" to 5: "highly likely") that they are likely to use these teaching tools in the future (M = 4.61, standard deviation [SD] = 0.53). Residents reported both significantly more geriatrics teaching by hospitalists (P < 0.05) and a borderline significant increase in their practice of geriatric clinical skills (P = 0.05).

CONCLUSIONS

A time-efficient geriatric faculty development program for hospitalists suggests improvement in the amount and quality of geriatrics teaching and skill practice among faculty and residents at an academic medical center. Concise faculty development programs within preexisting faculty meetings may be a feasible, successful method to increase geriatric skill development in the hospital setting.

Dissonance prevention program decreases thin-ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptoms: A preliminary experiment

OBJECTIVE

Because psychoeducational primary prevention programs for eating disorders have met with little success, this preliminary experiment tested a dissonance-based targeted preventive intervention.

METHOD

Female undergraduates (N = 30) with elevated body image concerns were assigned to a three-session intervention, wherein they voluntarily argued against the thin ideal, or a delayed-intervention control condition. Participants completed a baseline, termination, and a 1-month follow-up survey.

RESULTS

The intervention resulted in a subsequent decrease in thin-ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptomatology, with most changes remaining at the 1-month follow-up.

DISCUSSION

These preliminary results suggest that this dissonance-based targeted prevention intervention reduces bulimic pathology and known risk factors for eating disturbances, and provide experimental support for the claim that thin-ideal internalization contributes to body dissatisfaction, dieting, negative affect, and bulimic symptoms.