Shifting contours of boundaries: an exploration of inter-agency integration between hospital and community interprofessional diabetes programs.

This article reports on research into the relationships that emerged between hospital-based and community-based interprofessional diabetes programs involved in inter-agency care. Using constructivist grounded theory methodology we interviewed a purposive theoretical sample of 21 clinicians and administrators from both types of programs. Emergent themes were identified through a process of constant comparative analysis. Initial boundaries were constructed based on contrasts in beliefs, practices and expertise. In response to bureaucratic and social pressures, boundaries were redefined in a way that created role uncertainty and disempowered community programs, ultimately preventing collaboration. We illustrate the dynamic and multi-dimensional nature of social and symbolic boundaries in inter-agency diabetes care and the tacit ways in which hospitals can maintain a power position at the expense of other actors in the field. As efforts continue in Canada and elsewhere to move knowledge and resources into community sectors, we highlight the importance of hospitals seeing beyond their own interests and adopting more altruistic models of inter-agency integration.

Rethinking Context in Continuing Professional Development: From Identifying Barriers to Understanding Social Dynamics.

INTRODUCTION: For continuing professional development (CPD) to reach its potential to improve outcomes requires an understanding of the role of context and the influencing conditions that enable interventions to succeed. We argue that the heuristic use of frameworks to design and implement interventions tends to conceptualize context as defined lists of barriers, which may obscure consideration of how different contextual factors interact with and intersect with each other. METHODS: We suggest a framework approach that would benefit from postmodernist theory that explores how ideologies, meanings, and social structures in health care settings shape social practices. As an illustrative example, we conducted a Foucauldian discourse analysis of diabetes care to make visible how the social, historical, and political conditions in which clinicians experience, practice, and shape possibilities for behavior change. RESULTS: The discursive construction of continuing education as a knowledge translation mechanism assumes and is contingent on family physicians to implement guidelines. However, they enact other discursively constituted roles that may run in opposition. This paradoxical position creates a tension that must be navigated by family physicians, who may perceive it possible to provide good care without necessarily implementing guidelines. DISCUSSION: We suggest marrying "framework" thinking with postmodernist theory that explores how ideologies, meanings, and social structures shape practice behavior change. Such a proposed reconceptualization of context in the design of continuing professional development interventions could provide a more robust and nuanced understanding of how the dynamic relationships and interactions between clinicians, patients, and their work environments shape educational effectiveness.

Paradox of Patient-Centered Care and the Implications for Patient Involvement in Continuing Professional Development.

INTRODUCTION: Patient-centered care (PCC) is widely considered as essential in chronic disease management. As the underlying rationale for engaging patients in continuing professional development (CPD) is commonly described as fostering care that is more patient-centered, we hoped to understand the discursive conditions for how educators and health professionals can (or cannot) learn with, from, and about patients. METHODS: Using diabetes as a case, we conducted a Foucauldian discourse analysis of an archive of relevant policy documents, professional and educational texts, to explore different conceptualizations of practice and the implications for PCC. We also conducted in-depth interviews with a purposive sample of physicians to understand their experiences in providing and teaching PCC. We sought to understand: How has PCC been discursively constructed? Whose interests does advocating PCC serve? What are the implications for patient involvement in CPD? RESULTS: We describe three discursive constructions of PCC, each extending the reach of biomedical power. PCC as a disease intervention emphasizes knowing and relating to patients to normalize laboratory test results. PCC as a form of confession promotes patients to come to their own realizations to become responsible for their own health, but through the lens and evaluation of physicians. PCC as a disciplinary technique makes visible the possibility of using a checklist to judge physician competency in providing PCC. DISCUSSION: PCC may be constructed in ways that paradoxically reinforce rather than challenge conventional, provider-centric paradigms. Our results challenge educators to acknowledge the existence and effects of discourses when involving patients in the planning and delivery of CPD.

A web-based simulation of a longitudinal clinic used in a 4-week ambulatory rotation: a cohort study.

BACKGROUND: Residency training takes place primarily on inpatient wards. In the absence of a resident continuity clinic, internal medicine residents rely on block rotations to learn about continuity of care. Alternate methods to introduce continuity of care are needed. METHODS: A web-based tool, Continuity of Care Online Simulations (COCOS), was designed for use in a one-month, postgraduate clinical rotation in endocrinology. It is an interactive tool that simulates the continuing care of any patient with a chronic endocrine disease. Twenty-three residents in internal medicine participated in a study to investigate the effects of using COCOS during a clinical rotation in endocrinology on pre-post knowledge test scores and self-assessment of confidence. RESULTS: Compared to residents who did the rotation alone, residents who used COCOS during the rotation had significantly higher improvements in test scores (% increase in pre-post test scores +21.6 [standard deviation, SD, 8.0] vs. +5.9 [SD 6.8]; p < .001). Test score improvements were most pronounced for less commonly seen conditions. There were no significant differences in changes in confidence. Residents rated COCOS very highly, recommending its use as a standard part of the rotation and throughout residency. CONCLUSION: A stand-alone web-based tool can be incorporated into an existing clinical rotation to help residents learn about continuity of care. It has the most potential to teach residents about topics that are less commonly seen during a clinical rotation. The adaptable, web-based format allows the creation of cases for most chronic medical conditions.

Beginning a Diabetes Quality Improvement Project.

There is a large evidence-to-clinical practice gap in diabetes care. Application of quality improvement (QI) strategies can be used to improve gaps in care delivery. In this first of 3 articles in the diabetes QI primer series, we introduce the steps required to plan a QI project by using a case example for improving foot screening of people with diabetes. We review how to select an appropriate QI project, conduct a baseline gap analysis to clarify the QI problem and engage stakeholders to ensure successful implementation. The next 2 articles in the series will focus on root-cause analysis, selection of change ideas to improve care gaps, execution of the QI project using rapid-cycle testing and monitoring to sustain improvement over time.

Determining Root Causes and Designing Change Ideas in a Quality Improvement Project.

In this second article of our diabetes quality improvement primer series, readers will become familiar with various diagnostic tools used to understand the root causes of a quality problem. We discuss change concepts, and specific change ideas are developed to match the root causes. We review the application of a plan-do-study-act cycle from the Model for Improvement quality improvement framework to test 1 change idea and measure for the intended improvements.

Implementing Change Ideas, Interpreting Data and Sustaining Change in a Quality Improvement Project.

This article is the third and final installment in our diabetes quality improvement primer series. It summarizes how to interpret real-time data with run charts and highlights 4 key rules that can be applied to understand whether improvement is statistically significant. We also review the importance of outlining a family of measures, including outcome, process and balancing measures. Finally, we discuss strategies for sustaining change.

A Dialogic Approach to Teaching Person-Centered Care in Graduate Medical Education.

BACKGROUND: Training future physicians to provide compassionate, equitable, person-centered care remains a challenge for medical educators. Dialogues offer an opportunity to extend person-centered education into clinical care. In contrast to discussions, dialogues encourage the sharing of authority, expertise, and perspectives to promote new ways of understanding oneself and the world. The best methods for implementing dialogic teaching in graduate medical education have not been identified. OBJECTIVE: We developed and implemented a co-constructed faculty development program to promote dialogic teaching and learning in graduate medical education. METHODS: Beginning in April 2017, we co-constructed, with a pilot working group (PWG) of physician teachers, ways to prepare for and implement dialogic teaching in clinical settings. We kept detailed implementation notes and interviewed PWG members. Data were iteratively co-analyzed using a qualitative description approach within a constructivist paradigm. Ongoing analysis informed iterative changes to the faculty development program and dialogic education model. Patient and learner advisers provided practical guidance. RESULTS: The concepts and practice of dialogic teaching resonated with PWG members. However, they indicated that dialogic teaching was easier to learn about than to implement, citing insufficient time, lack of space, and other structural issues as barriers. Patient and learner advisers provided insights that deepened design, implementation, and eventual evaluation of the education model by sharing experiences related to person-centered care. CONCLUSIONS: While PWG members found that the faculty development program supported the implementation of dialogic teaching, successfully enabling this approach requires expertise, willingness, and support to teach knowledge and skills not traditionally included in medical curricula.

Effects of a Longitudinal Interprofessional Educational Outreach Program on Collaboration.

INTRODUCTION: Interprofessional education (IPE) interventions lack clarity regarding development and implementation, impeding a clear understanding of their role and effectiveness. The aim of this study was to identify whether and how an outreach program targeting interprofessional health care teams can improve self-efficacy and interprofessional collaboration (IPC). METHODS: A cohort study was conducted to explore the effect of the program on individual self-efficacy and perceived IPC and investigate factors affecting interprofessional learning and collaboration. The program was a two-year IPE program consisting of workshops, educational materials, and interworkshop support. Participants were physicians, nurses, dietitians, pharmacists, and social workers at two primary care teams in Toronto. Self-efficacy and team function were measured five times throughout the program. We used analysis of variance and t-tests to compare between teams and used Pearson correlations to estimate the relationship between self-efficacy and team function. One-on-one interviews investigated factors affecting IPC and the program's effect on IPC. RESULTS: Team function improved as the program progressed (P = .02); although it did not affect self-efficacy, there was an increasing correlation between self-efficacy and team function as the program progressed (P < .01 for workshop 5). Interviews revealed that trust, liability concerns, and geographic proximity were mediators of IPC. The workshops were perceived to enable trust building by increasing knowledge and allowing nonphysician team members to showcase their expertise. DISCUSSION: Our findings demonstrate that an IPE workshop, through role clarification, cultivation of trust, and a community of practice, can promote these elements. Trust in team members and geographic proximity are potential facilitators to IPC developed during an interprofessional program.

Frontline over ivory tower: key competencies in community-based curricula.

BACKGROUND: The Royal College of Physicians and Surgeons of Canada mandates that community experiences be incorporated into medicine-based specialties. Presently there is wide variability in community endocrine experiences across Canadian training programs. This is complicated by the paucity of literature providing guidance on what constitutes a 'community' rotation. METHOD: A modified Delphi technique was used to determine the CanMEDS competencies best taught in a community endocrinology curriculum. The Delphi technique is a qualitative-research method that uses a series of questionnaires sent to a group of experts with controlled feedback provided by the researchers after each survey round. The experts in this study included endocrinology program directors, community endocrinologists, endocrinology residents and recent endocrinology graduates. RESULTS: Thirty four out of 44 competencies rated by the panel were deemed suitable for a community curriculum. The experts considered the "Manager" role best taught in the community, while they considered the community least suitable to learn the "Medical Expert" competency. CONCLUSIONS: To our knowledge, this is the first time the content of a community-based subspecialty curriculum was determined using the Delphi process in Canada. These findings suggest that community settings have potential to fill in gaps in residency training in regards to the CanMEDS Manager role. The results will aid program directors in designing competency-based community endocrinology rotations and competency-based community rotations in other medical subspecialty programs.

Lymphocytic hypophysitis with a long latent period before development of a pituitary mass.

BACKGROUND: Lymphocytic hypophysitis is an autoimmune condition that commonly presents in women of childbearing age as hypopituitarism and a sellar mass. CASE REPORT: A 66-year-old woman presented with anterior pituitary dysfunction. Computed tomography imaging revealed a small hypodensity that was not felt to be the cause of the pituitary dysfunction. Eight years later, her vision rapidly deteriorated and MRI showed a pituitary mass lesion causing optic chiasm compression. Histological examination of the partially resected gland revealed evidence of lymphocytic hypophysitis. CONCLUSION: Our patient is an example of the variable presentation and course of lymphocytic hypophysitis. Such a long latent period between the initial presentation of adenohypophysial hypofunction and optic chiasm compression due to an enlarging pituitary mass has not been reported.

Defining Content for a Competency-based (CanMEDS) Postgraduate Curriculum in Ambulatory Care: a Delphi Study.

BACKGROUND: Ambulatory training in internal medicine has been noted to be dysfunctional and inadequate. In this study, we developed a set of competency-based outcomes specific to ambulatory care to guide the design, implementation and evaluation of instructional events to ensure that societal needs are addressed. METHODS: In 2007 a Delphi technique was used to reach consensus and define the priorities for competency-based training in ambulatory care for internal medicine residents. Four groups of stakeholders in Canada participated: program directors, members of the Canadian Society of Internal Medicine, recent graduates, and residents. RESULTS: Two rounds of the Delphi process were required to reach consensus on a set of sixty competency-based educational objectives in ambulatory care that were classified under the CanMEDS roles. The inclusion of recent graduates in this study resulted in the addition of non-clinical topics that would have otherwise been missed, falling under roles historically viewed as being challenging to teach and evaluate (Manager, Health Advocate). CONCLUSION: This study is the first time a Delphi-process has been used to define the priorities for ambulatory care training in internal medicine under a competency-based framework. The resulting compendium of competency-based objectives provides a foundation from which educators can design, evaluate and modify existing training experiences.