Improving participant feedback to continuing medical education presenters in internal medicine: a mixed-methods study.

BACKGROUND: Feedback is essential for improving the skills of continuing medical education (CME) presenters. However, there has been little research on improving the quality of feedback to CME presenters. OBJECTIVES: To validate an instrument for generating balanced and behavior-specific feedback from a national cross-section of participants to presenters at a large internal medicine CME course. DESIGN, SETTING, AND PARTICIPANTS: A prospective, randomized validation study with qualitative data analysis that included all 317 participants at a Mayo Clinic internal medicine CME course in 2009. MEASUREMENTS: An 8-item (5-point Likert scales) CME faculty assessment enhanced study form (ESF) was designed based on literature and expert review. Course participants were randomized to a standard form, a generic study form (GSF), or the ESF. The dimensionality of instrument scores was determined using factor analysis to account for clustered data. Internal consistency and interrater reliabilities were calculated. Associations between overall feedback scores and presenter and presentation variables were identified using generalized estimating equations to account for multiple observations within talk and speaker combinations. Two raters reached consensus on qualitative themes and independently analyzed narrative entries for evidence of balanced and behavior-specific comments. RESULTS: Factor analysis of 5,241 evaluations revealed a uni-dimensional model for measuring CME presenter feedback. Overall internal consistency (Cronbach alpha = 0.94) and internal consistency reliability (ICC range 0.88-0.95) were excellent. Feedback scores were associated with presenters' academic ranks (mean score): Instructor (4.12), Assistant Professor (4.38), Associate Professor (4.56), Professor (4.70) (p = 0.046). Qualitative analysis revealed that the ESF generated the highest numbers of balanced comments (GSF = 11, ESF = 26; p = 0.01) and behavior-specific comments (GSF = 64, ESF = 104; p = 0.001). CONCLUSIONS: We describe a practical and validated method for generating balanced and behavior-specific feedback for CME presenters in internal medicine. Our simple method for prompting course participants to give balanced and behavior-specific comments may ultimately provide CME presenters with feedback for improving their presentations.

Periprocedural anticoagulation management of patients with venous thromboembolism.

OBJECTIVE: Patients with venous thromboembolism (VTE) often require temporary warfarin interruption for an invasive procedure. The incidence of thromboembolism and bleeding related to periprocedural anticoagulation management of such patients is unknown. METHODS AND RESULTS: In a protocol-driven, inception cohort design study, all VTE patients (n=775) referred for periprocedural anticoagulation management (1997-2007) were followed-up to estimate the 3-month cumulative incidence of thromboembolism and bleeding. Patients were stratified by thrombus acuity (acute, <30 days; subacute, 31-90 days; or chronic > or =91 days). Decisions to provide "bridging" low-molecular-weight heparin were based on estimated thromboembolism and bleeding risk. Low-molecular-weight heparin was more often administered in acute (87%) and subacute (81%) VTE compared to chronic VTE (59%; P<0.001). The 3-month cumulative incidence of thromboembolism (1.8%), major hemorrhage (1.8%), and mortality (1.7%) were low and did not differ by management strategy. Active cancer was the only independent predictor of thrombotic recurrence (HR, 4.86; 95% CI, 1.6-14.5; P=0.005), major hemorrhage (HR, 6.8; 95% CI, 2.1-21.7; P=0.001), and death (HR, 32.7; 95% CI, 4.3-251.2; P=0.0008). CONCLUSIONS: Thromboembolism, bleeding, and death among VTE patients in whom anticoagulation is temporarily interrupted for an invasive procedure is low. Cancer patients require particular care given their propensity for both clotting and bleeding.

A novel advance directives course provides a transformative learning experience for medical students.

BACKGROUND: Inadequate physician training may be a barrier to physician-patient discussions of advance directives (ADs). DESCRIPTION: The purpose of this study was to determine the effects of an ADs course, which includes completing a directive, on medical students' perceived knowledge of and preparedness for discussing ADs with patients. All 4th-year medical students completed a 10-hr bioethics course comprising interactive lecture and small-group discussion formats. Curriculum content included ethical and legal aspects of ADs. An 8-item survey with free-text entry was administered 1 month after course completion. Internal consistency reliability of survey scores was determined. Two authors independently coded the free-text comments and reached consensus on underlying themes. EVALUATION: Of the 89 students who completed the survey (response rate 80%), 87 (98%) felt more knowledgeable and 88 (99%) better equipped to counsel patients about ADs. Forty-two (47%) reported they had counseled others to complete ADs during the month after the course. Internal consistency reliability of survey scores was very good (Cronbach's alpha =.78). Dominant themes of responses to the question, "What was the most eye opening, troubling, or difficult aspect about filling out your advance directive?" included difficulties articulating wishes, legal language, selecting a surrogate, and facing mortality. CONCLUSIONS: These findings suggest an ADs course that includes completing a directive enhances medical students' empathy for and preparedness to discuss ADs with patients.

A Process of Acceptance of Patient Photographs in Electronic Medical Records to Confirm Patient Identification.

Appropriate patient identification is a critical component of safe health care delivery. With increasing reliance on electronic medical records (EMRs), errors of test ordering and documentation have become commonplace. Incorporating patients' photograph in the EMR has considerably decreased error frequency and improved health care delivery by making it easier for physicians to identify a patient. We conducted a survey of all 35 physicians working in the Executive Health Program to determine the importance of having patient photographs in the EMR. Of the 35 physicians who received the survey, 26 (74.3%) responded, 24 (92.3%) of whom agreed that it was important to improve patient identification, care, and safety. Based on these data, we implemented a quality improvement project to increase the percentage of new patients having a photograph included in the EMR. Our goal was to increase photograph inclusion by more than 20% from baseline within 6 months without any unintended consequences (ie, not slowing down any of the workflow during the intake process). The intervention took place between June 1, 2015, and February 8, 2016. Using Define-Measure-Analyze-Improve-Control models, the baseline rate of photographs in the EMR was 49.5% (302 of 607). We initiated 3 Plan-Do-Study-Act cycles targeting awareness and data sharing campaigns. After the Plan-Do-Study-Act cycles, the weekly rate of patient photographs incorporated into the EMR was at 71.4%, which was significantly improved compared with baseline (F test, P<.001). No unintended consequences were identified. Increased inclusion of patient photographs in the EMR aided in patient identification and improved staff satisfaction with minimal interruption to workflow.

If you feed them, they will come: a prospective study of the effects of complimentary food on attendance and physician attitudes at medical grand rounds at an academic medical center.

BACKGROUND: Evidence suggests that attendance at medical grand rounds at academic medical centers is waning. The present study examined whether attendance at medical grand rounds increased after providing complimentary food to attendees and also assessed attendee attitudes about complimentary food. METHODS: In this prospective, before-and-after study, attendance at medical grand rounds was monitored from September 25, 2002, to June 2, 2004, using head counts. With unrestricted industry (eg, pharmaceutical) financial support, complimentary food was provided to medical grand rounds attendees beginning June 4, 2003. Attendance was compared during the pre-complimentary food and complimentary food periods. Attitudes about the complimentary food were assessed with use of a survey administered to attendees at the conclusion of the study period. RESULTS: The mean (+/- SD) overall attendance by head counts increased 38.4% from 184.1 +/- 90.4 during the pre-complimentary food period to 254.8 +/- 60.5 during the complimentary food period (P < .001). At the end of the study period, 70.1% of the attendee survey respondents indicated that they were more likely to attend grand rounds because of complimentary food, 53.6% indicated that their attendance increased as a result of complimentary food, and 53.1% indicated that their attendance would decrease if complimentary food was no longer provided. Notably, 80.3% indicated that food was not a distraction, and 81.7% disagreed that industry representatives had influence over medical grand rounds because of their financial support for the food. CONCLUSION: Providing free food may be an effective strategy for increasing attendance at medical grand rounds.

Current status of medical grand rounds in departments of medicine at US medical schools.

OBJECTIVE: To assess the status of medical grand rounds (MGR) as an educational endeavor. METHODS: A survey of 133 departments of medicine at US medical schools was performed from September 2003 to March 2004; the results were compared with those of a previous (1988) survey. RESULTS: Ninety-nine departments (74%) responded to the survey; all 99 conducted MGR. Providing updates in diagnosis, treatment, and medical research, educating house staff and faculty, and promoting collegiality were the most important objectives of MGR. Regarding objectives, responses to the current survey differed significantly from the responses to the 1988 survey for providing updates in medical research (P=.047), providing continuing medical education credit (P<.001), educating house staff (P=.048), and educating faculty (P<.001); the differences were primarily due to higher proportions of current survey respondents rating these objectives as "quite" or "very" important. The most common format was the didactic lecture. Case presentations were uncommonly used, and patients were rarely present. Only 44% of departments used educational needs assessments, and only 13% assessed knowledge gained by attendees. Feedback was irregularly provided to presenters. Most departments (64%) relied on industry to pay for MGR. Lack of presenter-attendee interaction and conflicting meetings were cited as Important challenges. Nevertheless, most (62%) of the current survey respondents thought the quality of MGR had increased. CONCLUSIONS: Departments of medicine regard MGR as an important educational and social endeavor. However, most departments use suboptimal teaching, planning, and evaluation methods, and many rely on industry to pay for MGR. Addressing these concerns and other challenges may enhance the value of MGR.

Strategies for improving attendance at medical grand rounds at an academic medical center.

OBJECTIVE: To evaluate, in this before-and-after study, the results of 5 strategies for improving attendance at medical grand rounds at a tertiary care academic medical center. METHODS: The strategies included (1) using electronic card readers to improve understanding of attendance patterns, (2) conducting yearly needs assessment surveys, (3) developing sessions of topical interest, (4) increasing formal participation by residents and faculty researchers, and (5) enhancing publicity. Attendance at medical grand rounds by Mayo Clinic faculty, fellows, residents, and others was measured by card readers between 1998 and 2001. RESULTS: After implementation of the 5 strategies, the mean +/- SD attendance (as measured by card readers) at medical grand rounds increased 39% from 99.0 +/- 24.6 persons in 1998 to 137.4 +/- 25.2 persons in 2001 (P < .001). CONCLUSION: An organized effort can improve attendance at medical grand rounds at an academic medical center.

Clinical pearls in perioperative medicine.

At the 2001 annual meeting of the American College of Physicians (ACP), a new and innovative teaching format, the "Clinical Pearls" session, was introduced. Clinical Pearls sessions were designed to teach physicians using clinical cases. The session format involves specialty speakers presenting a number of short cases to a physician audience. Each case is followed by a multiple-choice question, answered by each attendee using an electronic audience-response system. After a summary of the answer distribution is shown, the correct answer is displayed and the speaker discusses important teaching points and clarifies why one answer is most clinically appropriate. Each case presentation ends with 1 or 2 "Clinical Pearls," defined as a practical teaching point, supported by the literature, and generally not well known to most internists. The Clinical Pearls sessions are consistently one the most popular and well attended sessions at the American College of Physicians' national meeting each year. Herein, we present the Clinical Pearls in Perioperative Medicine, presented at the ACP National Meeting in San Francisco, California, April 11-13, 2013.