Twelve tips for teaching quality improvement in the clinical environment.

Medical educators are expected to teach quality improvement (QI) skills alongside traditional clinical skills such as physical examination and bedside manner. Educational resources for intensive training in QI have proliferated. However, many physicians lack the time or resources to undergo this training, and may struggle with teaching these skills to their learners. In response, we offer twelve tips to help physicians teach basic QI concepts in the clinical environment. By following these tips physicians will be able to engage their learners interest in QI and provide experiential learning that makes a lasting impact.

Three hospital admissions in 9 days to diagnose azathioprine hypersensitivity in a patient with Crohn's disease.

Azathioprine (AZA) is commonly used as a steroid-sparing immunosuppressive medication for the treatment of immune-mediated disorders including Crohn's disease. There is ample awareness of the more common adverse effects of this drug, including myelosuppression and risk of malignancy. We present a case of a 57-year-old man with fistulizing Crohn's disease who underwent 3 hospital admissions for recurrent fever with an extensive work-up for infection before the diagnosis of AZA hypersensitivity was made. Clinicians should be vigilant for AZA hypersensitivity as a cause of otherwise unexplained fever. Furthermore, in patients with inflammatory bowel disease (IBD), the signs and symptoms of AZA hypersensitivity may overlap with typical findings of inflammatory bowel disease flare.

Twelve tips for teaching evidence-based physical examination.

BACKGROUND: Practicing evidence-based physical examination (EBPE) requires clinicians to apply the diagnostic accuracy of PE findings in relation to a suspected disease. Though it is important to effectively teach EBPE, clinicians often find the topic challenging. AIMS: There are few resources available to guide clinicians on strategies to teach EBPE. We seek to fill that need by presenting tips for effectively teaching EBPE in the clinical context. METHODS: This report is based primarily on the authors' experience and is supported by the available literature. RESULTS: We present 12 practical tips targeting the clinician educator. The first six tips condense key preparatory steps for the teacher, including basic statistics underpinning EBPE. The final six tips provide specific guidance on how to teach EBPE in the clinical environment. CONCLUSIONS: By practicing the 12 tips provided, clinicians will develop the confidence needed to effectively teach EBPE in inpatient or outpatient settings.

Physical examination education in graduate medical education--a systematic review of the literature.

OBJECTIVES: There is widespread recognition that physical examination (PE) should be taught in Graduate Medical Education (GME), but little is known regarding how to best teach PE to residents. Deliberate practice fosters expertise in other fields, but its utility in teaching PE is unknown. We systematically reviewed the literature to determine the effectiveness of methods to teach PE in GME, with attention to usage of deliberate practice. DATA SOURCES: We searched PubMed, ERIC, and EMBASE for English language studies regarding PE education in GME published between January 1951 and December 2012. STUDY ELIGIBILITY CRITERIA: Seven eligibility criteria were applied to studies of PE education: (1) English language; (2) subjects in GME; (3) description of study population; (4) description of intervention; (5) assessment of efficacy; (6) inclusion of control group; and (7) report of data analysis. STUDY APPRAISAL AND SYNTHESIS METHODS: We extracted data regarding study quality, type of PE, study population, curricular features, use of deliberate practice, outcomes and assessment methods. Tabulated summaries of studies were reviewed for narrative synthesis. RESULTS: Fourteen studies met inclusion criteria. The mean Medical Education Research Study Quality Instrument (MERSQI) score was 9.0 out of 18. Most studies (n = 8) included internal medicine residents. Half of the studies used resident interaction with a human examinee as the primary means of teaching PE. Three studies "definitely" and four studies "possibly" used deliberate practice; all but one of these studies demonstrated improved educational outcomes. LIMITATIONS: We used a non-validated deliberate practice assessment. Given the heterogeneity of assessment modalities, we did not perform a meta-analysis. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: No single strategy for teaching PE in GME is clearly superior to another. Following the principles of deliberate practice and interaction with human examinees may be beneficial in teaching PE; controlled studies including these educational features should be performed to investigate these exploratory findings.

How to develop a competency-based examination blueprint for longitudinal standardized patient clinical skills assessments.

BACKGROUND: Objective Structured Clinical Exams (OSCEs) with standardized patients (SPs) are commonly used in medical education to assess learners' clinical skills. However, assessments are often discrete rather than intentionally developmentally sequenced. AIMS: We developed an examination blueprint to optimize assessment and feedback to learners with purposeful sequence as a series of longitudinally integrated assessments based on performance milestones. Integrated and progressive clinical skills assessments offer several benefits: assessment of skill development over time, systematic identification of learning needs, data for individualized feedback and learning plans, and baseline reference points for reassessment. METHODS: Using a competency-based medical education (CBME) framework, we translated pre-determined competency milestones for medical students' patient encounters into a four-year SP-based OSCE examination blueprint. RESULTS: Initial evaluation of cases using the blueprint revealed opportunities to target less frequently assessed competencies and to align assessments with milestones for each year. CONCLUSIONS: The examination blueprint can guide ongoing SP-based OSCE case design. Future iterations of examination blueprints can incorporate lessons learnt from evaluation data and student feedback.

5-oxoprolinemia causing elevated anion gap metabolic acidosis in the setting of acetaminophen use.

BACKGROUND: Anion gap metabolic acidosis is typically encountered in the emergency department (ED) setting as the result of shock, other endogenous metabolic derangements, or from exogenous toxicants. The differential diagnosis for toxicant-related acidosis (exemplified by common mnemonics) emphasizes acute overdose. CASE REPORT: The case we present manifested an anion gap (AG) metabolic acidosis due to a chronic intoxication: acetaminophen (APAP) overuse over a period of weeks. Lactic acidemia did not account for the AG. In this case, chronic APAP overuse, combined with decreased caloric intake and weight loss, was associated with excess 5-oxoproline (pyroglutamic acid), an organic acid accounting for the AG metabolic acidosis. Overproduction of 5-oxoproline is attributed to depleted glutathione stores, leading to perturbation in the γ-glutamyl cycle. The patient was treated with supportive care and with N-acetylcysteine (NAC). By repleting glutathione, NAC may facilitate the resolution of excess 5-oxoproline. CONCLUSIONS: The ED differential diagnosis of AG metabolic acidosis in chronic APAP overuse, especially with concomitant nutritional compromise, should include 5-oxoprolinemia.

Potential unintended consequences due to Medicare's "no pay for errors" rule? A randomized controlled trial of an educational intervention with internal medicine residents.

BACKGROUND: Medicare has selected 10 hospital-acquired conditions for which it will not reimburse hospitals unless the condition was documented as "present on admission." This "no pay for errors" rule may have a profound effect on the clinical practice of physicians. OBJECTIVE: To determine how physicians might change their behavior after learning about the Medicare rule. DESIGN: We conducted a randomized trial of a brief educational intervention embedded in an online survey, using clinical vignettes to estimate behavioral changes. PARTICIPANTS: At a university-based internal medicine residency program, 168 internal medicine residents were eligible to participate. INTERVENTION: Residents were randomized to receive a one-page description of Medicare's "no pay for errors" rule with pre-vignette reminders (intervention group) or no information (control group). Residents responded to five clinical vignettes in which "no pay for errors" conditions might be present on admission. MAIN MEASURES: Primary outcome was selection of the single most clinically appropriate option from three clinical practice choices presented for each clinical vignette. KEY RESULTS: Survey administered from December 2008 to March 2009. There were 119 responses (71%). In four of five vignettes, the intervention group was less likely to select the most clinically appropriate response. This was statistically significant in two of the cases. Most residents were aware of the rule but not its impact and specifics. Residents acknowledged responsibility to know Medicare documentation rules but felt poorly trained to do so. Residents educated about the Medicare's "no pay for errors" were less likely to select the most clinically appropriate responses to clinical vignettes. Such choices, if implemented in practice, have the potential for causing patient harm through unnecessary tests, procedures, and other interventions.

An Academic Research Coach: An Innovative Approach to Increasing Scholarly Productivity in Medicine.

BACKGROUND: Academic faculty who devote most of their time to clinical work often struggle to engage in meaningful scholarly work. They may be disadvantaged by limited research training and limited time. Simply providing senior mentors and biostatistical support has limited effectiveness. OBJECTIVE: We aimed to increase productivity in scholarly work of hospitalists and internal medicine physicians by integrating an Academic Research Coach into a robust faculty development program. DESIGN: This was a pre-post quality improvement evaluation. SETTING: This was conducted at the University of Washington in faculty across three academic-affiliated hospitals and 10 academic-affiliated clinics. PARTICIPANTS: Participants were hospitalists and internists on faculty in the Division of General Internal Medicine at the University of Washington. INTERVENTION: The coach was a 0.50 full time equivalent health services researcher with strong research methods, project implementation, and interpersonal skills. The coach consulted on research, quality improvement, and other scholarship. MEASUREMENTS: We assessed the number of faculty supported, types of services provided, and numbers of grants, papers, and abstracts submitted and accepted. RESULTS: The coach consulted with 49 general internal medicine faculty including 30 hospitalists who conducted 63 projects. The coach supported 13 publications, 11 abstracts, four grant submissions, and seven manuscript reviews. Forty-eight faculty in other departments benefited as co-authors. CONCLUSION: Employing a dedicated health services researcher as part of a faculty development program is an effective way to engage clinically oriented faculty in meaningful scholarship. Key aspects of the program included an accessible and knowledgeable coach and an ongoing marketing strategy.

Independent and mentored video review of OSCEs.

BACKGROUND: Video review of OSCE (objective structured clinical examination) performance allows students to analyse their performance, identify actions and behaviours for correction or reinforcement, and develop a plan for improvement of clinical skills. Student perceptions of the utility of independent and mentored video review are unknown. METHODS: We created a pilot programme of post-OSCE structured video review. Students were randomised to mentored (M) or independent (I) review. In the mentored group, a faculty member facilitated the process. Both groups completed an assessment rubric and created an action plan. We examined student perceptions of the process, helpful elements of each type of review and perceived impact after a follow-up OSCE. RESULTS: The mentored group (n = 12) was more comfortable watching themselves than the independent group (n = 11); using a five-point Likert scale, where 1 indicates 'strongly disagree' and 5 indicates 'strongly agree': 3.5 ± 1.2 (I) versus 4.5 ± 0.2 (M) (p = 0.02). The mentored group more strongly agreed that their clinical skills would improve: 3.6 ± 1.1 (I) versus 4.9 ± 0.2 (M) (p < 0.01). After the follow-up OSCE, the mentored group (n = 10) tended to feel more strongly that their clinical skills had improved compared with the independent group (n = 9): 3.6 ± 1.3 (I) versus 4.3 ± 0.7 (M) (p = 0.14). DISCUSSION: This pilot study demonstrates the utility of using a structured framework for post-OSCE video review, both for the assessment of performance and for the development of a behavioural action plan. There are advantages to using a mentor-guided model, but further study is needed to determine whether actual OSCE performances improve as a consequence. Video review of OSCE performance allows students to analyse their performance.

Parenthood During Graduate Medical Education: A Scoping Review.

PURPOSE: To conduct a scoping review of the literature on parenthood during graduate medical education (GME) and to develop a conceptual framework to inform policy and guide research. METHOD: The authors searched PubMed and Embase for articles published from January 1993 through August 7, 2017, using a query framework that combined the concepts of "person" (e.g., "trainee") and "parenthood" (e.g., "breastfeeding"). They included studies describing parenthood or pregnancy of trainees in U.S. GME training programs. Two authors independently screened citations and abstracts and performed kappa coefficient tests to evaluate interreviewer reliability. Two authors performed a full-text review of and extracted data from each included article, and 4 authors coded data for all articles. The authors used descriptive statistics and qualitative synthesis to analyze data. RESULTS: Ninety articles met inclusion criteria, and nearly half (43/90; 48%) were published between 2010 and 2017. The authors developed 6 themes that surround resident parenthood: well-being, maternal health, others' perceptions, relationships, program preparation, and policy. They mapped these themes by relationship of stakeholders (e.g., infant and family, institutions) to the resident-parent to create a conceptual framework describing parenthood during GME. CONCLUSIONS: The findings from this scoping review have implications for policy and research. Those authoring parental leave policies could collaborate with national board leaders to develop consistent standards and include nontraditional families. Gaps in the literature include the effect of resident parenthood on patient care, postpartum health, and policy execution. Research in these areas would advance the literature on parenthood during residency.

Observing bedside rounds for faculty development.

BACKGROUND: Bedside rounds are an ideal opportunity for clinical teaching. We previously offered faculty development on balancing learner autonomy, patient care and teaching. We noticed that participants often asked whether attending physicians and learners shared the same perceptions of the key elements (patient-centredness, efficiency and educational value) of bedside rounds. Understanding these perceptions and identifying areas of discordance would inform faculty development for optimal bedside rounds. METHODS: At a university hospital we observed 16 attending physicians and 47 learners over 112 patient encounters. We noted the length of rounds and the number of interruptions. Participants were surveyed on their perception of the attending physicians' efficacy in preparing the team for rounds, and the efficiency and educational value of the rounds. Bedside rounds are an ideal opportunity for clinical teaching FINDINGS: After the same rounds, compared with the attending physicians, learners perceived the patient-centredness, efficiency and educational value of the rounds to be significantly higher. Learners rated attending physicians higher than attending physicians did themselves on learner autonomy, appropriate supervision, conferring responsibility for the care plan to learners and not interrupting. There was no correlation between interruptions and length of the rounds, or learner or attending physician perception of key elements of the rounds. Learners tended to attribute greater efficacy to attending physicians for team preparation than attending physicians did themselves. CONCLUSION: We identified salient beliefs and practices on bedside teaching. Our findings suggest that identifying shared goals and expectations, and creating metrics to define successful rounds, may help attending physicians to better synergize with learners. Interruptions need not be eschewed completely for the purpose of achieving efficient rounds. Integrating these measures into faculty development may bolster the quality of bedside rounds.

Faculty development for hospitalists: structured peer observation of teaching.

BACKGROUND: Hospitalists provide much of the clinical teaching in internal medicine, yet formative feedback to improve their teaching is rare. METHODS: We developed a peer observation, assessment, and feedback program to improve attending hospitalist teaching. Participants were trained to identify 10 optimal teaching behaviors using a structured observation tool that was developed from the validated Stanford Faculty Development Program clinical teaching framework. Participants joined year-long feedback dyads and engaged in peer observation and feedback on teaching. Pre- and post-program surveys assessed confidence in teaching, performance of teaching behaviors, confidence in giving and receiving feedback, attitudes toward peer observation, and overall satisfaction with the program. RESULTS: Twenty-two attending hospitalists participated, averaging 2.2 years (± 2.1 years standard deviation [SD]) experience; 15 (68%) completed pre- and post-program surveys. Confidence in giving feedback, receiving feedback, and teaching efficacy increased (1 = strongly disagree, 5 = strongly agree, mean ± SD): "I can accurately assess my colleagues' teaching skills," (pre = 3.2 ± 0.9 vs post = 4.1 ± 0.6, P < 0.01), "I can give accurate feedback to my colleagues" (pre = 3.4 ± 0.6 vs post = 4.2 ± 0.6, P < 0.01), and "I am confident in my ability to teach students and residents" (pre = 3.2 ± 0.9 vs post = 3.7 ± 0.8, P = 0.026). CONCLUSIONS: Peer observation and feedback of teaching increases hospitalist confidence in several domains that are essential for optimizing teaching. Further studies are needed to examine if educational outcomes are improved by this program.

An advanced quality improvement and patient safety elective.

BACKGROUND: Practising doctors must be competent in quality improvement (QI) and patient safety (PS). Despite this need, QI and PS have yet to be fully integrated into the undergraduate medical curriculum. Furthermore, there are few resources available for motivated senior medical students to receive advanced training prior to starting residency. To address these needs, we piloted an elective in QI/PS for senior medical students. METHODS: We measured changes in knowledge, attitude and QI/PS skills with before and after surveys and skill assessments. Post-elective measures included an assessment of reaction to the curriculum and an assessment of a QI project proposal. RESULTS: Six students participated in two 2-week electives. Mean knowledge test scores improved after the elective [mean score (SD)]: before, 7.3 (1.4), versus after, 8.2 (0.4); p = 0.19. There were improvements in confidence in all aspects queried, and this was significant in six of the seven confidence questions. Students had high motivation for future QI/PS involvement both before and after the elective. Validated measures assessing QI/PS skills showed high levels of performance both before and after the elective. Experiential components of the elective were most highly valued. DISCUSSION: Motivated students may not have the confidence needed to effectively actuate their desire to incorporate QI/PS in their continuing training and careers. This 2-week elective significantly improved students' confidence and maintained their motivation for QI/PS work. Experiential activities may be particularly beneficial for students to learn QI/PS throughout medical school.

MSSA brain abscess and pyomyositis presenting as brain tumour and DVT.

A 66-year-old man with a recent radiographic diagnosis of a parietal brain tumour presented with severe left thigh pain that prevented ambulation. On examination, his left anterior thigh was mildly swollen without erythema. Initial concern was for deep vein thrombosis in the setting of brain malignancy or necrotising soft tissue infection. Subsequent imaging and biopsies revealed methicillin sensitive Staphylococcus aureus (MSSA) pyomyositis of the left thigh and MSSA brain abscess.