Patient Satisfaction in Academic Pain Management Centers: How Do We Compare?

PURPOSE OF REVIEW: The aim of the study was to investigate patient satisfaction amongst academic pain management centers and associated factors. RECENT FINDINGS: Approximately 25% of pain management centers perform better than other practices on Press Ganey surveys. The majority of respondents (96%) indicated that pain management practices were uniquely positioned to receive poorer scores on patient satisfaction surveys. The majority of respondents (20/26), who reported a reason, indicated that limiting opioid prescribing led to poor patient satisfaction scores. Eighty-three percent of respondents indicated that they received pressure from administrators to improve patient satisfaction scores. The opioid epidemic in the USA must be addressed in order to diminish the senseless loss of life that is occurring in staggering numbers. The quality of care physicians provide has increasingly been assessed via patient satisfaction surveys. The results of these surveys often are utilized to provide financial incentives to physicians to obtain higher satisfaction scores. In the field of pain management, physicians may experience pressure to prescribe opioids in order to obtain higher patient satisfaction scores.

Teaching Safe Opioid Prescribing During the Opioid Epidemic: Results of the 2018 Clerkship Directors in Internal Medicine Survey.

BACKGROUND: Educating medical trainees across the continuum is essential to a multifaceted strategy for addressing the opioid epidemic. OBJECTIVE: To assess the current state of internal medicine clerkship content on safe opioid prescribing and opioid use disorder, and barriers to curriculum implementation. DESIGN: National Annual (2018) Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred thirty-four clerkship directors at all Liaison Committee of Medical Education accredited US medical schools with CDIM membership as of October 1, 2018. MAIN MEASURES: The survey section on safe opioid prescribing and opioid use disorder education in the internal medicine clerkship addressed assessment of current curricula, perceived importance of curricula, barriers to implementation, and plans to start or expand curricula. Descriptive statistics were used to summarize responses, and Pearson's chi-square and Fisher's exact tests for statistical comparisons. KEY RESULTS: The survey response rate was 82% (110/134). Overall 54.1% of responding institutions reported covering one or more topics related to safe opioid prescribing or opioid use disorder in the internal medicine clerkship. A preponderance of clerkship directors (range 51-86%) reported that various opioid-related topics were important to cover in the internal medicine clerkship. Safe opioid prescribing topics were covered more frequently than topics related specifically to opioid use disorder. The main barriers identified included time (80.9%) and lack of faculty expertise (65.5%). CONCLUSIONS: Clerkship directors agreed that incorporating safe opioid prescribing and opioid use disorder topics in the internal medicine clerkship is important, despite wide variation in current curricula. Addressing curricular time constraints and lack of faculty expertise in internal medicine clerkships will be key to successfully integrating content to address the opioid epidemic.

Medical Oversight and Scope of Practice of Medical Spas (Med-Spas).

BACKGROUND: The regulation of medical spas (med-spas) in the United States varies considerably from state to state with important ramifications for patient safety. OBJECTIVE: To describe the current state of med-spas in the United States and degree of medical oversight in these facilities. MATERIALS AND METHODS: Descriptive study based on web search and standardized phone interviews of med-spas in the most heavily populated cities in each state of the United States. Information obtained included the following: whether medical directors were listed; if so, whether they were advertised as being on site; medical directors' training and board certification; and services offered. RESULTS: Of 247 medical spas reviewed, 72% advertised a medical director on their website, and 6.5% claimed that the director was on site. Of listed medical directors, 41% were trained in dermatology and/or plastic surgery. In phone interviews, 79% of med-spas endorsed the medical director to be board certified, and 52% stated that the medical director was on site less than 50% of the time. CONCLUSION: There is significant variation in medical directorship and oversight among medical spas in the United States. Appropriate regulation of medical directors' training and the degree of oversight provided are warranted to optimize patient safety.

Competitive Advantage of MBA for Physician Executives: A Systematic Literature Review.

In response to systemic challenges facing the US healthcare system, many medical students, residents and practicing physicians are pursuing a Master in Business Administration (MBA) degree. The value of such proposition remains poorly defined. The aim of this review is to analyze current literature pertaining to the added value of MBA training for physician executives (PEs). We hypothesized that physicians who supplement their clinical expertise with business education gain a significant competitive advantage. A detailed literature search of four electronic databases (PubMed, SCOPUS, Embase and ERIC) was performed. Included were studies published between Jan 2000 and June 2017, focusing specifically on PEs. Among 1580 non-duplicative titles, we identified 23 relevant articles. Attributes which were found to add value to one's competitiveness as PE were recorded. A quality index score was assigned to each article in order to minimize bias. Results were tabulated by attributes and by publication. We found that competitive domains deemed to be most important for PEs in the context of MBA training were leadership (n = 17), career advancement opportunities (n = 12), understanding of financial aspects of medicine (n = 9) and team-building skills (n = 10). Among other prominent factors associated with the desire to engage in an MBA were higher compensation, awareness of public health issues/strategy, increased negotiation skills and enhanced work-life balance. Of interest, the learning of strategies for reducing malpractice litigation was less important than the other drivers. This comprehensive systemic review supports our hypothesis that a business degree confers a competitive advantage for PEs. Physician executives equipped with an MBA degree appear to be better equipped to face the challenge of the dynamically evolving healthcare landscape. This information may be beneficial to medical schools designing or implementing combined dual-degree curricula.

Recent trends in publications of US vascular surgery program directors.

Objective In order to examine the academic productivity of US vascular surgery program directors, the number of vascular publications listed in PubMed from 2001 to 2015 for US vascular surgery program directors was reviewed. We suggest that this can be used as a benchmark for academic productivity. Methods The names of the program directors were taken from the Accreditation Council for Graduate Medical Education (ACGME) website at two time points: December 2009 (Independent Programs) and December 2015 (Independent + Integrated). This was used to query PubMed, which listed 5196 publications: 3284 from 2001 to 2009 and 1912 from 2010 to 2015. Results There were 104 program directors (2001-2009) and 114 program directors (2010-2015) with average number of publications in PubMed per program director as 3.68/year (SD ± 2.31) and 2.80/year (SD ± 2.73), respectively ( P = .01). From 2001 to 2009, 1215 (37%) and in 2010 to 2015, 860 (45%) of the publications were from Journal of vascular surgery. The top third produced 67% and 69% of publications in the two time-points. No statistical difference was ascertained regionally: northeast, southeast, midwest and west ( P = .46). The numbers of publications/year decreased by 17% compared to first 10 years. From 2001 to 2009, there were no programs with no publications which increased to five and three with no Journal of Vascular Surgery publications which increased to 21 in 2010-2015. The independent and integrated program directors published average of 2.85 (SD ± 2.69) and 3.47 (SD ± 3.1) total publications; 1.25 (SD ± 1.4) and 3.47 (SD ± 1.7) Journal of Vascular Surgery papers/year, respectively ( P = .28, P = .23). Changes in the study subject were noted by percentage of total publications: endovascular lower extremity arterial (4.7% to 8.9%), Thoracic Endovascular Aortic Repair (TEVAR) (4.5% to 9.9%), Arterio-Venous (AV) access (0.0% to 3.0%), basic science (14.7% to 6.8%), open thoracic (3.0% to 0.6%). Conclusion There seems to be a significant decline in the number of publications over the last 15 years. Yet, the subject of the publications has progressed from Open to TEVAR with an increase in endovascular publications. However, basic science publications reduced by half.

Focused Transthoracic Cardiac Ultrasound: A Survey of Training Practices.

OBJECTIVE: The role of focused assessment by transthoracic echocardiography or focused cardiac ultrasound (FoCUS) in the perioperative setting is uncertain and evolving. To the authors' knowledge, there are no studies that evaluate the current teaching practices regarding FoCUS in US anesthesiology residencies. The authors surveyed residents and residency program directors to examine the frequency, type, and variability of instruction regarding training of FoCUS. DESIGN: A survey study. SETTING: Anesthesiology residency programs in the United States. PARTICIPANTS: All 133 Accreditation Council for Graduate Medical Education anesthesiology program directors and their residents were invited to participate in an anonymous electronic survey. MEASUREMENTS AND MAIN RESULTS: In all, 292 respondents replied to the survey, and 245 were included in the analysis. Overall response rate was 30% for program directors. The majority of the respondents were trainees (83.7%). FoCUS training was reported to be present by 36% of respondents. Respondents from institutions in which>10% of attending physicians used FoCUS were nearly 3 times as likely as those in which fewer attending physicians used FoCUS to report presence of FoCUS training program. The most common training mode is lectures with simulation (34%), followed by bedside training (31%). The most frequently reported responsible training parties were anesthesiologists (75%), followed by cardiologists (14%). Although FoCUS training is relatively rare, most respondents (187 of 205 residents and 26 of 40 program directors) said that FoCUS should be the standard in training for anesthesia residents. CONCLUSIONS: Despite the increasing availability and use of ultrasound in clinical practice, FoCUS-related use and training remain uncommon in anesthesiology. Trainees in anesthesiology are not receiving adequate instruction in FoCUS despite their desire to acquire this skill.

Quantifying publication scholarly activity of psychiatry residency training directors.

OBJECTIVE: The authors quantify the number of PubMed-indexed publications by psychiatry program directors during a 5-year observation period. METHODS: The authors obtained the names of general adult, child and adolescent, and geriatric psychiatry program directors from the ACGME website and entered them into a PubMed.gov database search. Then, they counted the number of indexed publications from July 2008 to June 2013 and categorized them by academic year. RESULTS: The median number of publications was one for adult psychiatry program directors (n=184), one for child and adolescent directors (n=121), and three for geriatric psychiatry directors (n=58). CONCLUSIONS: The number of PubMed-indexed publications for program directors of general adult, child and adolescent, and geriatric psychiatry residencies is relatively low. Further research is needed to identify and examine the challenges facing program directors that may limit their ability to participate in this form of scholarly activity.

Impact of the information age on residency training: communication, access to public information, and clinical care.

Access to technology in practice helps physicians manage information, communicate, and research topics; however, those in training receive almost no formal preparation for integrating web-based technologies into practice. One reason for this is that many faculty-aside from junior faculty or those in recent generations-did not grow up using Internet communication, may use it minimally, if at all, in their own practices, and may know little about its forms and varieties. This report presents a case to illustrate how these disparities may play out in the supervisory situation and makes suggestions about helping supervisors integrate technology-awareness into their teaching.

Talent management and physician leadership training is essential for preparing tomorrow's physician leaders.

Talent management and leadership development is becoming a necessity for health care organizations. These leaders will be needed to manage the change in the delivery of health care and payment systems. Appointment of clinically skilled physicians as leaders without specific training in the areas described in our program could lead to failure. A comprehensive program such as the one described is also needed for succession planning and retaining high-potential individuals in an era of shortage of surgeons.

Examining clinical performance feedback in Patient-Aligned Care Teams.

BACKGROUND: The move to team-based models of health care represents a fundamental shift in healthcare delivery, including major changes in the roles and relationships among clinical personnel. Audit and feedback of clinical performance has traditionally focused on the provider; however, a team-based model of care may require different approaches. OBJECTIVE: Identify changes in audit and feedback of clinical performance to primary care clinical personnel resulting from implementing team-based care in their clinics. DESIGN: Semi-structured interviews with primary care clinicians, their department heads, and facility leadership at 16 geographically diverse VA Medical Centers, selected purposively by their clinical performance profile. PARTICIPANTS: An average of three interviewees per VA medical center, selected from physicians, nurses, and primary care and facility directors who participated in 1-hour interviews. APPROACH: Interviews focused on how clinical performance information is fed back to clinicians, with particular emphasis on external peer-review program measures and changes in feedback associated with team-based care implementation. Interview transcripts were analyzed, using techniques adapted from grounded theory and content analysis. KEY RESULTS: Ownership of clinical performance still rests largely with the provider, despite transitioning to team-based care. A panel-management information tool emerged as the most prominent change to clinical performance feedback dissemination, and existing feedback tools were seen as most effective when monitored by the nurse members of the team. Facilities reported few, if any, appreciable changes to the assessment of clinical performance since transitioning to team-based care. CONCLUSIONS: Although new tools have been created to support higher-quality clinical performance feedback to primary care teams, such tools have not necessarily delivered feedback consistent with a team-based approach to health care. Audit and feedback of clinical performance has remained largely unchanged, despite material differences in roles and responsibilities of team members. Future research should seek to unpack the nuances of team-based audit and feedback, to better align feedback with strategic clinical goals.

Resident duty hours: a survey of internal medicine program directors.

INTRODUCTION: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new Common Program Requirements to regulate duty hours of resident physicians, with three goals: improved patient safety, quality of resident education and quality of life for trainees. We sought to assess Internal Medicine program director (IMPD) perceptions of the 2011 Common Program Requirements in July 2012, one year following implementation of the new standards. METHODS: A cross-sectional study of all IMPDs at ACGME-accredited programs in the United States (N = 381) was performed using a 32-question, self-administered survey. Contact information was identified for 323 IMPDs. Three individualized emails were sent to each director over a 6-week period, requesting participation in the survey. Outcomes measured included approval of duty hours regulations, as well as perceptions of changes in graduate medical education and patient care resulting from the revised ACGME standards. RESULTS: A total of 237 surveys were returned (73% response rate). More than half of the IMPDs (52%) reported "overall" approval of the 2011 duty hour regulations, with greater than 70% approval of all individual regulations except senior resident daily duty periods (49% approval) and 16-hour intern shifts (17% approval). Although a majority feel resident quality of life has improved (55%), most IMPDs believe that resident education (60%) is worse. A minority report that quality (8%) or safety (11%) of patient care has improved. CONCLUSION: One year after implementation of new ACGME duty hour requirements, IMPDs report overall approval of the standards, but strong disapproval of 16-hour shift limits for interns. Few program directors perceive that the duty hour restrictions have resulted in better care for patients or education of residents. Although resident quality of life seems improved, most IMPDs report that their own workload has increased. Based on these results, the intended benefits of duty hour regulations may not yet have been realized.

Readiness for practice: a survey of neurosurgery graduates and program directors.

BACKGROUND: Postgraduate neurosurgical education is undergoing significant reform, including transition to a competency-based training model. To support these efforts, the purpose of this study was to determine neurosurgical graduates' and program directors' (PDs) opinions about graduates' level of competence in reference to the 2010 Royal College Objectives of Training in Neurosurgery. METHODS: An electronic survey was distributed to Canadian neurosurgery PDs and graduates from 2011. The questionnaire addressed graduates' abilities in nonprocedural knowledge and skills, CanMEDS roles, proficiency with core neurosurgical procedures and knowledge of complex neurosurgical techniques. RESULTS: Thirteen of 22 (59%) graduate and 17/25 (65%) PD surveys were completed. There were no significant differences between PD and graduate responses. Most respondents agreed that these graduates possess the knowledge and skills expected of an independently practicing neurosurgeon across current objectives of training. A small proportion felt some graduates did not achieve this level of proficiency on specific vascular, functional, peripheral nerve and endoscopic procedures. This was partially attributed to limited exposure to these procedures during training and perceptions that some techniques required fellowship-level training. CONCLUSIONS: Graduating neurosurgical residents are perceived to possess a high level of proficiency in the majority of neurosurgical practice domains. Inadequate exposure during training or a perception that subspecialists should perform some procedures may contribute to cases where proficiency is not as high. The trends identified in this study could be monitored on an ongoing basis to provide supplemental data to guide curricular decisions in Canadian neurosurgical training.

Academic productivity of directors of ACGME-accredited residency programs in surgery and anesthesiology.

BACKGROUND: Scholarly activity is expected of program directors of Accreditation Council for Graduate Medical Education (ACGME)-accredited residency training programs. Anesthesiology residency programs are cited more often than surgical programs for deficiencies in academic productivity. We hypothesized that this may in part reflect differences in scholarly activity between program directors of anesthesiology and surgical trainings programs. To test the hypothesis, we examined the career track record of current program directors of ACGME-accredited anesthesiology and surgical residency programs at the same institutions using PubMed citations and funding from the National Institutes of Health (NIH) as metrics of scholarly activity. METHODS: Between November 1, 2011 and December 31, 2011, we obtained data from publicly available Web sites on program directors at 127 institutions that had ACGME-accredited programs in both anesthesiology and surgery. Information gathered on each individual included year of board certification, year first appointed program director, academic rank, history of NIH grant funding, and number of PubMed citations. We also calculated the h-index for a randomly selected subset of 25 institution-matched program directors. RESULTS: There were no differences between the groups in number of years since board certification (P = 0.42), academic rank (P = 0.38), or years as a program director (P = 0.22). However, program directors in anesthesiology had less prior or current NIH funding (P = 0.002), fewer total and education-related PubMed citations (both P < 0.001), and a lower h-index (P = 0.001) than surgery program directors. Multivariate analysis revealed that the publication rate for anesthesiology program directors was 43% (95% confidence interval, 0.31-0.58) that of the corresponding program directors of surgical residency programs, holding other variables constant. CONCLUSIONS: Program directors of anesthesiology residency programs have considerably less scholarly activity in terms of peer-reviewed publications and federal research funding than directors of surgical residency programs. As such, this study provides further evidence for a systemic weakness in the scholarly fabric of academic anesthesiology.

Medical director responsibilities for outpatient cardiac rehabilitation/secondary prevention programs: 2012 update: a statement for health care professionals from the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart Association.

Medical directors of cardiac rehabilitation/secondary prevention (CR/SP) programs are responsible for the safe and effective delivery of high-quality CR/SP services to eligible patients. Yet, the training and resources for CR/SP medical directors are limited. As a result, there appears to be considerable variability throughout CR/SP programs in the United States in the roles, responsibilities, and engagement of CR/SP medical directors. Since the publication of the 2005 scientific statement from the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation regarding medical director responsibilities for outpatient CR/SP programs, significant changes have occurred. This statement updates the responsibilities of CR/SP medical directors, in view of changes in federal legislation and regulations and changes in health care delivery and clinical practice that impact the roles and responsibilities of CR/SP medical directors.

Director of anesthesiology for liver transplantation: existing practices and recommendations by the United Network for Organ Sharing.

A new Organ Procurement and Transplantation Network/United Network for Organ Sharing bylaw recommends that all centers appoint a director of liver transplant anesthesia with a uniform set of criteria. We obtained survey data from the Liver Transplant Anesthesia Consortium so that we could compare existing criteria for a director in the United States with the current recommendations. The data set included responses from adult academic liver transplant programs before the new bylaw. The respondent rates were within statistical limits to exclude sampling bias. All centers had a director of liver transplant anesthesia. The criteria varied between institutions, and the data suggest that the availability of resources influenced the choice of criteria. The information suggests that the criteria used in the new bylaw reflect existing practices. The bylaw plays an important role in supporting emerging leadership roles in liver transplant anesthesia and brings greater uniformity to the directorship position.