Impact of COVID-19 visitation policies and hospital capacity on discharge readiness in medicine patients.

Background: COVID-19 impacted the experience of being hospitalized with the widespread adoption of strict visitation policies to ensure healthcare worker safety. One result was decreased time of caregivers at the bedside of hospitalized patients. Objective: To understand the impact of pandemic-related system effects on patient-reported discharge preparation. Design: This mixed methods study included interviews with a sample of discharged patients during April 2020, and quantitative hospital data from April 2020 to February 2021. Participants: 616 patients completed a measure of discharge readiness on their day of discharge and 38 patients completed interviews about their discharge experiences. Main measures: Readiness for discharge (RHDS), visitation policies, ward structure changes, COVID-19-unit census, time into the COVID-19 pandemic, patient characteristics (age, sex, race/ethnicity), admission type (planned/unplanned, for COVID-19), and discharge destination (home, home health, skilled nursing). Key results: Adult patients aged 30-45 (vs. young and older adult patients) and those being discharged to places other than home (e.g., skilled nursing facility) or to out-of-state residences report lower readiness (p < 0.05) on RHDS. Patient interviews revealed some gaps in discharge communication but, overall, patients expressed high discharge readiness and few concerns about how COVID-19 system changes impacted their discharge preparation. Conclusions: While there is some evidence that visitation policies and unit census may impact patient perceptions of discharge preparation, personal characteristics contributed more significantly to discharge readiness than system changes during COVID-19. Participant interviews demonstrated agreement, as most participants were discharged home and identified strong personal feelings of readiness for discharge.Clinical trials registration: ClinicalTrials.gov ID NCT04248738, https://clinicaltrials.gov/ct2/show/NCT04248738. Supplementary Information: The online version contains supplementary material available at 10.1007/s44250-023-00060-8.

Impact of Opt-Out Therapy Appointments on Resident Physicians' Mental Health, Well-Being, Stigma, and Willingness to Engage.

Background Health care professionals report higher levels of mental health symptoms, pandemic-related stress, personal health concerns, and reduced proactive coping, especially in recent years marked by the COVID-19 pandemic. As physician utilization rates of mental health and well-being services remain low, the need for preemptive care is crucial. Objective The present study sought to ascertain satisfaction, value, and attitude toward future mental health services among resident physicians. Methods Throughout the 2020-2021 academic year, resident physicians within 8 training programs at a large academic training hospital were offered single opt-out mental health appointments from hospital-funded, graduate medical education wellness staff at no cost to the resident. Appointments were conducted virtually during protected work time. A survey was sent to participants within 2 weeks following their appointment. Results A total of 153 residents (postgraduate years 1 to 7) were offered one-time opt-out appointments. Overall, 91 (59%) residents attended their opt-out appointments. Survey response rate was 57% (n=52). Respondents reported high levels of satisfaction (96%, 50 of 52), felt the appointment was worth their time (96%, 50 of 52), and felt that the opt-out appointments demonstrated training programs cared about their well-being (94%, 49 of 52). Nearly all residents (98%, 51 of 52) recommended appointments be offered to future residents. Most respondents (80%, 42 of 52) indicated that appointments increased their willingness to engage in mental health services. Conclusions Opt-out appointments increased resident willingness to engage in mental health services, positive attitudes toward future mental health services, perceived training program's care about their well-being, and reduced perceived mental illness stigma.

Medical Student Experiential Learning in Telesimulation.

OBJECTIVES: Telesimulation utilizes telecommunication technology to engage learners in simulation while in different physical locations. Despite this potential advantage, understanding of the student experience and assessment of student learning in telesimulation activities is limited. This study evaluates medical student emotional experience and self-identified learning in telesimulation through the Kolb experiential learning framework and qualitative analysis. METHODS: Fourth-year medical students enrolled in the Spencer Fox Eccles School of Medicine at the University of Utah participated in 3 telesimulation activities as part of a required internal medicine course. Students were surveyed regarding their satisfaction with the activity (N = 114) and responded to questions about their emotional experience and self-identified areas of learning. Free-text responses were analyzed using qualitative content analysis to identify themes until thematic saturation (N = 66). RESULTS: Students were highly satisfied with telesimulation, with greater than 90% of students expressing a positive view of simulation realism, debrief quality, and group size. Themes of anxiety and uncertainty, confidence versus incompetence, team dynamics, fun, and difficult patient interaction were identified regarding the emotional experience. Themes of communication and teamwork, managing emotions, information gathering, differential diagnosis, resource reference, executing treatment, and medical knowledge were identified regarding student-identified learning. CONCLUSION: In this analysis of medical student experiences with telesimulation, we found students have rich emotional, cognitive, and behavioral experiences and self-identify learning across a variety of domains. Our findings support further study of telesimulation for medical student learning and demonstrate how assessment of outcomes via Kolb framework, using the learner's reflective observation and self-identified learning, may help better define learning outcomes from simulation.

Capturing growth curves of medical students' clinical skills performance.

INTRODUCTION: A benefit of a milestone or Entrustable Professional Activity (EPA) assessment framework is the ability to capture longitudinal performance with growth curves using multi-level modelling (MLM). Growth curves can inform curriculum design and individualised learning. Residency programmes have found growth curves to vary by resident and by milestone. Only one study has analysed medical students' growth curves for EPAs. Analysis of EPA growth curves is critical because no change in performance raises concerns for EPAs as an assessment framework. METHODS: Spencer Fox Eccles School of Medicine-University of Utah students' workplace-based assessment ratings for 7 EPAs were captured at 3 time-points in years 3-4 of AY2017-2018 to AY2020-2021. MLM was used to capture EPA growth curves and determine if variation in growth curves was explained by internal medicine (IM) clerkship order. FINDINGS: A curvilinear slope significantly captured 256 students' average ratings overtime for EPA1a-history-taking, EPA2-clinical reasoning, EPA3-diagnostics, EPA5-documentation and EPA6-presentation, and a linear slope significantly captured EPA9-teamwork ratings, p ≤ 0.001. Growth curves were steepest for EPA2-clinical reasoning and EPA3-diagnostics. Growth curves varied by students, p < 0.05 for all EPA ratings, but IM clerkship rotation order did not significantly explain the variance, p > 0.05. DISCUSSION: The increase in ratings from Year 3 to Year 4 provides validity evidence for use of EPAs in an assessment framework. Students may benefit from more curriculum/skills practice for EPA2-clinical reasoning and EPA3-diagnostics prior to year 3. Variation in student's growth curves is important for coaching and skill development; a one size fits all approach may not suffice.

Comparison of internal medicine applicant and resident characteristics with performance on ACGME milestones.

Internal medicine (IM) residency programs select applicants based on several metrics. Factors predicting success during residency are unclear across studies. To identify whether specific applicant or resident factors are associated with IM resident performance using ACGME milestones. We tested for associations between applicant factors available prior to the start of IM residency and resident factors measured during IM residency training, and resident performance on ACGME milestones across three consecutive years of IM training between 2015-2020. Univariable and multivariable linear regression modeling was used to test associations. Eighty-nine categorical IM residents that completed 3 consecutive years of training were included. Median age was 28 years (IQR 27-29) and 59.6% were male. Mean ACGME milestone scores increased with each post-graduate year (PGY) from 3.36 (SD 0.19) for PGY-1, to 3.80 (SD 0.15) for PGY-2, to 4.14 (SD 0.15) for PGY-3. Univariable modeling suggested referral to the clinical competency committee (CCC) for professionalism concerns was negatively associated with resident performance during each PGY. No applicant or resident factors included in the final multivariable regression models (age at starting residency, USMLE Step scores, interview score, rank list position, ITE scores) were associated with ACGME milestone scores for PGY-1 and PGY-2. Referral to the CCC for professionalism was negatively associated with resident performance during PGY-3. Residency selection factors did not predict resident milestone evaluation scores. Referral to the CCC was associated with significantly worse resident evaluation scores, suggesting professionalism may correlate with clinical performance.

Making the Personal Statement "Truly Personal": Recommendations From a Qualitative Case Study of Internal Medicine Program and Associate Program Directors.

Background: The personal statement is an integral part of a residency application but little guidance exists for medical students about what content to include. Objective: We use the framework of isomorphism, the process by which institutions model themselves after one another, to understand what internal medicine program directors (PDs) and associate program directors (APDs) recommend be included in the personal statement and how programs use personal statements in their selection of applicants to interview and rank. Methods: Semi-structured phone interviews were conducted between August and October 2020 with 13 academic PDs and APDs, who were selected for participation based on program size and geographic location. Interviews were recorded, transcribed, and coded using content analysis. Results: Effective personal statements should be well-written, present unique information, and demonstrate fit with a residency program. PDs and APDs recommended against expressing lack of interest in a program or highlighting negative personal characteristics. PDs and APDs used personal statements to distinguish between applicants and noted that personal statements help programs form an impression of the applicant. Consensus among PDs and APDs about what personal statements should include and how they are used indicates that isomorphism influences the match process. Conclusions: Our study found that the personal statement is a valued part of the residency application when it includes unique attributes and reveals personal values that align with that of the program. Additionally, PDs and APDs noted that when applicants highlight their unique characteristics, it can help distinguish themselves from others.

Hospital Discharge During COVID-19: The Role of Social Resources.

CLINICAL TRIAL REGISTRATION: This study is a part of a parent study: Social Needs and Resources in the Evaluation and Enhancement of Discharge Support. The trial registry is clinicaltrials.gov, number NCT04248738. Initial release was 1/27/2020 and the first participant was enrolled on 2/4/2020. Link to the information on the registry: https://clinicaltrials.gov/ct2/show/NCT04248738.

Impact of Hospitalist Team Structure on Patient-Reported Satisfaction with Physician Performance.

BACKGROUND: Patient experience is valuable because it reflects how patients perceive the care they receive within the healthcare system and is associated with clinical outcomes. Also, as part of the Hospital Value-Based Purchasing (HVBP) program, the Center for Medicare and Medicaid Services (CMS) rewards hospitals with financial incentives for patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. It is unclear how the addition of residents and advanced practice clinicians (APCs) to hospitalist-led inpatient teams affects patient satisfaction as measured by the HCAHPS and Press Ganey survey. OBJECTIVE: To compare patient satisfaction with hospitalists on resident, APC, and solo hospitalist teams measured by HCAHPS and Press Ganey physician performance domain survey results. DESIGN: Retrospective observational cohort study. PARTICIPANTS: All patients discharged from the Internal Medicine inpatient service between July 1, 2015, and July 1, 2018, who met HCAHPS survey eligibility criteria and completed a patient experience survey. MAIN MEASURES: HCAHPS and Press Ganey physician performance domain survey results. KEY RESULTS: No differences were observed in the selection of "top box" scores on the HCAHPS physician performance domain between resident, APC, and solo hospitalist teams. Adjusted Press Ganey physician performance domain survey results demonstrated significant differences between solo hospitalist and resident teams, with solo hospitalists having higher scores in three areas: time physician spent with you (4.58 vs. 4.38, p = 0.050); physician kept you informed (4.63 vs. 4.43, p = 0.047); and physician skill (4.80 vs. 4.63, p = 0.027). Solo hospitalists were perceived to have higher physician skill in comparison with hospitalist-APC teams (4.80 vs. 4.69, p = 0.042). CONCLUSION: While Press Ganey survey results suggest that patients have greater satisfaction with physicians on solo hospitalist teams, these differences were not observed on the HCAHPS physician performance survey domain, suggesting physician team structure does not impact HVBP incentive payments by CMS.

Milestone Implementation's Impact on Narrative Comments and Perception of Feedback for Internal Medicine Residents: a Mixed Methods Study.

BACKGROUND: Feedback is a critical element of graduate medical education. Narrative comments on evaluation forms are a source of feedback for residents. As a shared mental model for performance, milestone-based evaluations may impact narrative comments and resident perception of feedback. OBJECTIVE: To determine if milestone-based evaluations impacted the quality of faculty members' narrative comments on evaluations and, as an extension, residents' perception of feedback. DESIGN: Concurrent mixed methods study, including qualitative analysis of narrative comments and survey of resident perception of feedback. PARTICIPANTS: Seventy internal medicine residents and their faculty evaluators at the University of Utah. APPROACH: Faculty narrative comments from 248 evaluations pre- and post-milestone implementation were analyzed for quality and Accreditation Council for Graduate Medical Education competency by area of strength and area for improvement. Seventy residents were surveyed regarding quality of feedback pre- and post-milestone implementation. KEY RESULTS: Qualitative analysis of narrative comments revealed nearly all evaluations pre- and post-milestone implementation included comments about areas of strength but were frequently vague and not related to competencies. Few evaluations included narrative comments on areas for improvement, but these were of higher quality compared to areas of strength (p < 0.001). Overall resident perception of quality of narrative comments was low and did not change following milestone implementation (p = 0.562) for the 86% of residents (N = 60/70) who completed the pre- and post-surveys. CONCLUSIONS: The quality of narrative comments was poor, and there was no evidence of improved quality following introduction of milestone-based evaluations. Comments on areas for improvement were of higher quality than areas of strength, suggesting an area for targeted intervention. Residents' perception of feedback quality did not change following implementation of milestone-based evaluations, suggesting that in the post-milestone era, internal medicine educators need to utilize additional interventions to improve quality of feedback.

Emergency medicine and internal medicine trainees' smartphone use in clinical settings in the United States.

PURPOSE: Smartphone technology offers a multitude of applications (apps) that provide a wide range of functions for healthcare professionals. Medical trainees are early adopters of this technology, but how they use smartphones in clinical care remains unclear. Our objective was to further characterize smartphone use by medical trainees at two United States academic institutions, as well as their prior training in the clinical use of smartphones. METHODS: In 2014, we surveyed 347 internal medicine and emergency medicine resident physicians at the University of Utah and Brigham and Women's Hospital about their smartphone use and prior training experiences. Scores (0%-100%) were calculated to assess the frequency of their use of general features (email, text) and patient-specific apps, and the results were compared according to resident level and program using the Mann-Whitney U-test. RESULTS: A total of 184 residents responded (response rate, 53.0%). The average score for using general features, 14.4/20 (72.2%) was significantly higher than the average score for using patient-specific features and apps, 14.1/44 (33.0%, P<0.001). The average scores for the use of general features, were significantly higher for year 3-4 residents, 15.0/20 (75.1%) than year 1-2 residents, 14.1/20 (70.5%, P=0.035), and for internal medicine residents, 14.9/20 (74.6%) in comparison to emergency medicine residents, 12.9/20 (64.3%, P= 0.001). The average score reflecting the use of patient-specific apps was significantly higher for year 3-4 residents, 16.1/44 (36.5%) than for year 1-2 residents, 13.7/44 (31.1%; P=0.044). Only 21.7% of respondents had received prior training in clinical smartphone use. CONCLUSION: Residents used smartphones for general features more frequently than for patient-specific features, but patient-specific use increased with training. Few residents have received prior training in the clinical use of smartphones.

Discussion of alternatives, risks and benefits in pediatric acute care.

OBJECTIVE: Across adult healthcare, discussions of alternatives, risks and benefits vary in inclusiveness or are even absent. We examine these discussions and their associated factors in pediatric visits. METHODS: Coders noted speaker and recipient for alternatives, risks and benefits from 98 videotaped visits. Outcomes included discussion of alternatives, risks or benefits (yes/no) and involvement of parent or child in discussions (active or passive). Bivariate techniques were used to relate visit factors to outcomes. RESULTS: Most visits included discussion of alternatives (58% of visits), risks (54%) and benefits (69%). Longer visits were more likely to include risk discussions. For alternatives, active parent/child involvement was more likely with college graduate parents; for risks active involvement was more likely with female and more experienced physicians. Parents and children raised risks more frequently than benefits, often focusing on disadvantages such as taste or frequency/duration of therapy. CONCLUSION: Most pediatric visits include alternatives, risks and benefits but parent/child involvement in raising these topics is limited. PRACTICE IMPLICATIONS: When parents or children initiate these discussions, they often mention risks salient to adherence. Future work could explore whether longer visits or interventions targeted for specific participants could foster such discussions.