The Impact of Internal Medicine Clerkship Characteristics and NBME Subject Exams on USMLE Step 2 Clinical Knowledge Exam Performance.

BACKGROUND: Residency program directors will likely emphasize the United States Medical Licensing Exam (USMLE) Step 2 clinical knowledge (CK) exam more during residency application given the recent USMLE Step 1 transition to pass/fail scoring. We examined how internal medicine clerkship characteristics and NBME subject exam scores affect USMLE Step 2 CK performance. DESIGN: The authors used univariable and multivariable generalized estimating equations to determine associations between Step 2 CK performance and internal medicine clerkship characteristics and NBME subject exams. The sample had 21,280 examinees' first Step 2 CK scores for analysis. RESULTS: On multivariable analysis, Step 1 performance (standardized ß = 0.45, p < .001) and NBME medicine subject exam performance (standardized ß = 0.40, p < .001) accounted for approximately 60% of the variance in Step 2 CK performance. Students who completed the internal medicine clerkship last in the academic year scored lower on Step 2 CK (Mdiff = -3.17 p < .001). Students who had a criterion score for passing the NBME medicine subject exam scored higher on Step 2 CK (Mdiff = 1.10, p = .03). There was no association between Step 2 CK performance and other internal medicine clerkship characteristics (all p > 0.05) nor with the total NBME subject exams completed (ß=0.05, p = .78). CONCLUSION: Despite similarities between NBME subject exams and Step 2 CK, the authors did not identify improved Step 2 CK performance for students who had more NBME subject exams. The lack of association of Step 2 CK performance with many internal medicine clerkship characteristics and more NBME subject exams has implications for future clerkship structure and summative assessment. The improved Step 2 CK performance in students that completed their internal medicine clerkship earlier warrants further study given the anticipated increase in emphasis on Step 2 CK.

Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic.

BACKGROUND: Transitions of care from specialty and acute settings to primary care abound. Compared to the continuity in end-of-shift handoffs, care transitions involve provider communication between practices and facilities with their own cultures and bureaucracies. Using the transition from acute care to outpatient primary care for stroke/transient ischemic attack (TIA) patients as a case study, this qualitative research explored communication practices and institutional arrangements among clinical providers responsible for longitudinal management of hypertension. In this study, researchers investigated the barriers and facilitators of effective communication between acute stroke/TIA inpatient and primary care providers at a Veterans Affairs Medical Center. METHODS: A multidisciplinary team conducted consensus-based coding and thematic analysis of semistructured interviews with 21 clinical providers (9 with primary responsibilities for inpatient care and 12 with primary responsibilities in outpatient, primary care). RESULTS: Thematic analysis of responses identified three factors that influenced communication between clinical providers: (1) consistent, concise but complete medication and treatment plans; (2) reliable, standardized discharge documentation; (3) use of multiple modes of communication. Participants identified cultural barriers, including challenges with rotating providers at a teaching hospital and local discharge practices. CONCLUSION: Ambiguity about who is being handed off to and time pressures in the acute setting may lead inpatient providers to give lower priority to discharge communication, leaving outpatient providers with low-quality information. While electronic templates have standardized key components of discharge documentation, improvement opportunities remain. Increased awareness of the challenges and opportunities on each side of the care transfer could foster communication practices that systematically account for the information needs of inpatient and outpatient providers.

Patient safety stories: a project utilizing narratives in resident training.

Incident reports have traditionally been the vehicle for identifying, assessing, and responding to quality gaps in hospitals. Yet because of a variety of barriers, residents often fail to participate in this formal process. The authors created a project to engage residents in incident reporting through the use of an online, anonymous narrative format, faculty-facilitated discussion groups, and involvement of patient safety officers in the educational process. During three months, 36 residents submitted a total of 79 stories about patient care that did not "go as intended." The authors reviewed and scored each story for contributing factors and outcomes. The residents met monthly in small groups with trained faculty facilitators to analyze the stories, which were also shared with the patient safety officers. The stories, narratives of both personal involvement and observed events, ranged from near-misses to sentinel events. Key contributing factors included lapses of professionalism, decision errors, communication/information mishaps, transition mix-ups, and workload difficulties. The narrative format proved a feasible tool for collecting significant, previously unrecognized patient safety issues. Internal medicine residents were willing to discuss gaps in care when given the tools and opportunity for anonymous storytelling and blame-free dialogue.

A Rapid Usability Evaluation (RUE) Method for Health Information Technology.

Usability testing can help generate design ideas to enhance the quality and safety of health information technology. Despite these potential benefits, few healthcare organizations conduct systematic usability testing prior to software implementation. We used a Rapid Usability Evaluation (RUE) method to apply usability testing to software development at a major VA Medical Center. We describe the development of the RUE method, provide two examples of how it was successfully applied, and discuss key insights gained from this work. Clinical informaticists with limited usability training were able to apply RUE to improve software evaluation and elected to continue to use this technique. RUE methods are relatively simple, do not require advanced training or usability software, and should be easy to adopt. Other healthcare organizations may be able to implement RUE to improve software effectiveness, efficiency, and safety.