Are All Teaching Activities Valued the Same? Their Relative Worth Is in the Eye of the Beholder.

OBJECTIVES: The pressures for generating revenue from clinical activities dissuade clinician-educators from teaching; taking the steps to develop an educational value system is a way to recognize and perhaps support education. We compared the perceived educational value of diverse pedagogical activities during clinical training from students, residents, and faculty in medical and surgical specialties. METHODS: Between 2016 and 2017, a survey among medical students, residents, and faculty from medical (internal medicine, pediatrics) or surgical (general surgery, obstetrics and gynecology) departments was conducted at an academic medical center that sponsors 88 training programs. Participants ranked teaching activities relative to their perceived teaching importance. RESULTS: In total, 156 subjects participated (48 core teaching faculty, 68 residents, and 40 medical students). Teaching in the wards was the highest-ranked teaching activity for medical (mean 1.6) and surgical specialties (mean 1.9). For medicine and pediatrics, active teaching activities were ranked higher (mean 2.9, 95% confidence interval [CI] 2.8-3.0) than passive teaching activities (mean 5.3, 95% CI 5.1-5.5, P < 0.001). Similarly, for surgery and obstetrics and gynecology, active teaching activities were ranked higher (mean 3.6, 95% CI 3.3-3.9) than passive teaching activities (mean 5.2, 95% CI 4.8-5.5, P < 0.001). CONCLUSIONS: Medical students, residents, and faculty across specialties have a high degree of agreement regarding the ranking of diverse pedagogical activities; such correlation will facilitate the interpretation of educational value units across specialties.

The Privilege of Being a Physician and the Immutable Values of the Medical Profession.

The medical profession has been, is, and will continue to be under siege by a variety of sources most of which are external to the profession and not under our control. The consequences of this unrelenting pressure are leading to burnout, early retirement, and low career satisfaction. Arguably, these and perhaps other not-well-recognized factors has influenced the well-being of physicians and culminated in a high suicide rate in the profession. However, the pressures that our profession have been under over the last 2,500 years, albeit less pronounced than the current ones, have been successfully navigated by going back to the foundational values of medicine that are both intemporal and immutable. We should stand by these principles and defend the description of the Ideal Internist; these principles should guide how health care is delivered as they are rooted in the fiduciary commitment our profession has made to society since the Hippocratic Oath was written.

Connecting the dots: like watching a movie critically.

Acquisition of expertise in the diagnosis and management of patients requires years of practice; exposure to diverse clinical entities is critical as well as the myriad ways in which the same disease can present in a given patient. However, this repeated exposure has to be accompanied by two critical elements; first, the novice needs the guidance of an expert or master to appreciate the nuances and subtleties in making a diagnosis or taking a course of action. Second, and perhaps most importantly, the physician needs to acquire the habit of reflecting on and in actions during the clinical encounter. Unguided repetition during formative years or lack of critical introspection during practice hinders the progression to expertise. In a way, a complex clinical encounter is akin to watching a complex movie; it takes repeated exposure to the movie to understand the subtleties the director is utilizing to understand the plot in its entirety.

Use of ecological momentary assessment to determine which structural factors impact perceived teaching quality of attending rounds.

INTRODUCTION: Providing high-quality teaching to residents during attending rounds is challenging. Reasons include structural factors that affect rounds, which are beyond the attending's teaching style and control. OBJECTIVE: To develop a new evaluation tool to identify the structural components of ward rounds that most affect teaching quality in an internal medicine (IM) residency program. METHODS: The authors developed a 10-item Ecological Momentary Assessment (EMA) tool and collected daily evaluations for 18 months from IM residents rotating on inpatient services. Residents ranked the quality of teaching on rounds that day, and questions related to their service (general medicine, medical intensive care unit, and subspecialty services), patient census, absenteeism of team members, call status, and number of teaching methods used by the attending. RESULTS: Residents completed 488 evaluation cards over 18 months. This found no association between perceived teaching quality and training level, team absenteeism, and call status. We observed differences by service (P < .001) and patient census (P  =  .009). After adjusting for type of service, census was no longer significant. Use of a larger variety of teaching methods was associated with higher perceived teaching quality, regardless of service or census (P for trend < .001). CONCLUSIONS: The EMA tool successfully identified that higher patient census was associated with lower perceived teaching quality, but the results were also influenced by the type of teaching service. We found that, regardless of census or teaching service, attendings can improve their teaching by diversifying the number of methods used in daily rounds.

The importance of measuring competency-based outcomes: standard evaluation measures are not surrogates for clinical performance of internal medicine residents.

BACKGROUND: Despite recent emphasis on educational outcomes, program directors still rely on standard evaluation techniques such as tests of knowledge and subjective ratings. PURPOSES: To assess the correlation of standard internal medicine (IM) residency evaluation scores (attending global evaluations, In-Training examination, and Mini-Clinical Examination Exercise) with documented performance of preventive measures for continuity clinic patients. METHODS: Cross-sectional study of 132 IM residents attending an IM teaching clinic, July 2000 to June 2003, comparing standard evaluations with chart audit. RESULTS: Mean resident performance ranged from 53% (SD = 24) through 89% (SD = 20) across the 6 preventive measures abstracted from 1,102 patient charts. We found weak and mostly not significant correlations between standard measures and performance of preventive services. CONCLUSIONS: Standard measures are not adequate surrogates for measuring clinical outcomes. This supports the Accreditation Council for Graduate Medical Education's recommendations to incorporate novel Toolbox measures, like chart audit, into residency evaluations.

Can residents accurately abstract their own charts?

PURPOSE: To assess the accuracy of residents' record review, using trained abstractors as a gold standard comparison. METHOD: In 2005, the authors asked 74 residents to review their own charts (n = 392) after they received brief instruction on both how to locate data on the medical record and how to use a data abstraction form. Trained abstractors then re-reviewed these charts to assess performance of preventive health care measures in medicine (smoking screening, smoking cessation advice, mammography, colon cancer screening, lipid screening, and pneumonia vaccination) and pediatrics (parent smoking screening, parent smoking cessation advice, car seat safety, car restraint use, eye alignment, and immunizations up to date). The authors then quantified agreement between the two record reviews and assessed the sensitivity and specificity of the residents versus the trained abstractors. RESULTS: Overall resident-measured performance was similar (within 5%) to that of the trained abstractor for five of six measures in medicine and four of six in pediatrics. For the various measures, sensitivity of resident-measured performance ranged from 100% to 15% and specificity from 100% to 33% compared with the trained abstractors. Relative to the trained abstractor record review, residents did not overestimate their performance. Most residents' (81%) relative performance rankings did not change when the basis for the ranking was resident measured versus trained abstractor measured. CONCLUSIONS: Residents' self-abstraction can be an alternative to costly trained abstractors. Appropriate use of these data should be carefully considered, acknowledging the limitations.

Internal medicine training in the 21st century.

Many are calling for changes for internal medicine training, arguing that changes in the practice environment mandate changes in how the internal medicine residency is structured. Residency could be shorter, more conducive to role differentiation among general internists, and more supportive of subspecialization. Training could provide more experience in ambulatory care, multidisciplinary team-based care, chronic disease management, and quality improvement. The authors contend that the claim that internal medicine training ought to mirror internal medicine practice is mistaken. Many changes now proposed would likely damage if not destroy the consultant-generalist ideal of traditional internal medicine training which remains critical to effective medical care in the 21st century. The authors propose a model for training similar in structure but different in spirit from contending models. This model, like others, would involve a core experience in the first two years with tracking in the final year; unlike others, it would provide a conceptually coherent experience based on internal medicine's traditional ideal. Outpatient experience would be subsidiary to a predominantly inpatient experience, and it would be structured in blocks rather than continuity clinics. Twenty-first-century internists will continue to face what has always been the internist's task: the resolution of complex and ill-defined patient problems into proper diagnoses and therapeutic options. Contemporary internal medicine training must fit trainees for that task and must, thus, continue to offer the training experience necessary for the realization of the Oslerian ideal: a substantial apprenticeship taking care of inpatients with a wide range of medical illnesses.

A pilot study using nominal group technique to assess residents' perceptions of successful attending rounds.

BACKGROUND: Ward attending rounds are fundamental for internal medicine residency training. An improved understanding of interns' and residents' perceptions of attending rounds should inform training programs and attending physicians. OBJECTIVES: The aim of this study was to assess residents' perceptions of successful attending rounds. DESIGN: We convened two groups of interns and two groups of residents, to elicit their perceptions on attending rounds. SUBJECTS: Participants were recruited by e-mail and conference announcements from the 49 interns and 80 residents in the internal medicine and medicine-pediatrics residency programs. MEASUREMENTS: The nominal group technique (NGT) uses a structured group process to elicit and prioritize answers to a carefully articulated question. MAIN RESULTS: Seven interns (14%) identified 27 success factors and ranked attending approachability and enthusiasm and high quality teaching as most important. A second group of six (12%) interns identified 40 detractors and ranked having "mean attendings," receiving disrespectful comments, and too long or too short rounds as the most significant detractors. Nine (11%) residents identified 32 success factors and ranked attention to length of rounds, house staff autonomy, and establishing goals/expectations as the most important success factors. A second group of six (8%) residents identified 34 detractors and ranked very long rounds, interruptions and time constraints, and poor rapport between team members as the most significant detractors). CONCLUSIONS: Although there was some overlap in interns' and residents' perceptions of attending rounds, interns identified interpersonal factors as the most important factors; whereas residents viewed structural factors as most important. These findings should assist attending physicians improve the way they conduct rounds targeting both interns and residents needs.

Taking apart the art: the risk of anatomizing clinical competence.

The Accreditation Council for Graduate Medical Education (ACGME) is encouraging medical residency programs to objectively assess their trainees for possession of six general clinical competencies by the completion of residency training. This is the thrust of the ACGME Outcome Project, now in its seventh year. As residency programs seek to integrate the general competencies into clinical training, educators have begun to suggest that objective assessment of clinical competence may be able to guide decisions about length of training and timing of subspecialization. The authors contend that higher-level competence is not amenable to assessment by the objective comparison of resident performance with learning objectives, even if such objectives are derived from general competencies. Present-day attempts at such assessment echo the uses to which medical schools hoped to put curricular learning objectives in the 1970s. Objective assessment may capture knowledge and skills that amount to the "building blocks" of competence, but it cannot elucidate or scrutinize higher-level clinical competence. Higher-level competence involves sensitivity to clinical context and can be validly appraised only in such a context by fully competent clinical appraisers. Such assessment is necessarily subjective, but it need not be unreproducible if raters are trained and if sampling of trainee performance is sufficiently extensive. If the ACGME approach to clinical competency is indeed brought to bear on decisions about training length and subspecialization timing, the present apprenticeship model for clinical training in the United States, a model both remarkably successful and directly descendant from Osler's innovations, will be under threat.

Does residency training improve performance of physical examination skills?

BACKGROUND: Few studies use objective structured clinical examinations (OSCEs) to measure physical examination skills of internal medicine residents. Little is known about performance by year of residency training. PURPOSE: To determine differences between postgraduate year (PGY)-1 and PGY-3 residents on performance and comfort of physical examination skills. METHODS: In a cross-sectional study, we tested 16 PGY-1 (weeks 0 and 4) and 8 PGY-3 internal medicine residents with a five-station OSCE. RESULTS: PGY-3 residents performed better than PGY-1 week 0 residents (P = 0.03) but not PGY-1 week 4 residents (P = 0.42). PGY-1 resident performance improved after 1 month of inpatient wards experience (P < 0.001). PGY-3 residents had higher comfort compared to PGY-1 week 0 residents (P = 0.003) but not PGY-1 week 4 residents (P = 0.10). CONCLUSIONS: Senior residents performed better and were more confident on physical examination skills, but the difference disappeared after 1 month of internship. This calls into question how much further learning occurs with physical examination throughout residency training.

Implementing achievable benchmarks in preventive health: a controlled trial in residency education.

PURPOSE: To evaluate the Preventive Health Achievable Benchmarks Curriculum, a multifaceted improvement intervention that included an objective, practice-based performance evaluation of internal medicine and pediatric residents' delivery of preventive services. METHOD: The authors conducted a nonrandomized experiment of intervention versus control group residents with baseline and follow-up of performance audited for 2001-2004. All 130 internal medicine and 78 pediatric residents at two continuity clinics at the University of Alabama School of Medicine, Birmingham, participated. Performance of preventive care was assessed by structured chart review. The multifaceted feedback curriculum included individualized performance feedback, academic detailing by faculty, and collective didactic sessions. The main outcome was difference in receipt of preventive care for patients seen by intervention and control residents, comparing baseline and follow-up. RESULTS: Charts were reviewed for 3,958 patients. Receipt of preventive care increased for patients of intervention residents, but not for patients of control residents. For the intervention group, significant increases occurred for five of six indicators in internal medicine: smoking screening, quit smoking advice, colon cancer screening, pneumonia vaccine, and lipid screening; and four of six in pediatrics: parental quit smoking advice, car seats, car restraints, and eye alignment (p < .05 for all). For control residents, no consistent improvements were seen. There was greater improvement for intervention than for control residents for four of six indicators in internal medicine, and two of six in pediatrics. CONCLUSIONS: Using a multifaceted feedback curriculum, the authors taught residents about the care they provide and improved documented patient care.

Measuring resident physicians' performance of preventive care. Comparing chart review with patient survey.

BACKGROUND: The Accreditation Council for Graduate Medical Education has suggested various methods for evaluation of practice-based learning and improvement competency, but data on implementation of these methods are limited. OBJECTIVE: To compare medical record review and patient surveys on evaluating physician performance in preventive services in an outpatient resident clinic. DESIGN: Within an ongoing quality improvement project, we collected baseline performance data on preventive services provided for patients at the University of Alabama at Birmingham (UAB) Internal Medicine Residents' ambulatory clinic. PARTICIPANTS: Seventy internal medicine and medicine-pediatrics residents from the UAB Internal Medicine Residency program. MEASUREMENTS: Resident- and clinic-level comparisons of aggregated patient survey and chart documentation rates of (1) screening for smoking status, (2) advising smokers to quit, (3) cholesterol screening, (4) mammography screening, and (5) pneumonia vaccination. RESULTS: Six hundred and fifty-nine patient surveys and 761 charts were abstracted. At the clinic level, rates for screening of smoking status, recommending mammogram, and for cholesterol screening were similar (difference <5%) between the 2 methods. Higher rates for pneumonia vaccination (76% vs 67%) and advice to quit smoking (66% vs 52%) were seen on medical record review versus patient surveys. However, within-resident (N=70) comparison of 2 methods of estimating screening rates contained significant variability. The cost of medical record review was substantially higher ($107 vs $17/physician). CONCLUSIONS: Medical record review and patient surveys provided similar rates for selected preventive health measures at the clinic level, with the exception of pneumonia vaccination and advising to quit smoking. A large variation among individual resident providers was noted.

Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of a personal digital assistant (PDA)-based clinical decision support system (CDSS) on nonsteroidal anti-inflammatory drug (NSAID) prescribing safety in the outpatient setting. DESIGN: The design was a randomized, controlled trial conducted in a university-based resident clinic. Internal medicine residents received a PDA-based CDSS suite. For intervention residents, the CDSS included a prediction rule for NSAID-related gastrointestinal risk assessment and treatment recommendations. Unannounced standardized patients (SPs) trained to portray musculoskeletal symptoms presented to study physicians. Safety outcomes were assessed from the prescriptions given to the SPs. Each prescription was reviewed by a committee of clinicians blinded to participant, intervention group assignment, and baseline or follow-up status. MEASUREMENTS: Prescriptions were judged as safe or unsafe. The main outcome measure was the differential change in unsafe prescribing of NSAIDs for the intervention versus the control group. RESULTS: At baseline, the mean proportion of cases per physician with unsafe prescriptions for the two groups was similar (0.27 vs. 0.29, p > 0.05). Controlling for baseline performance, intervention participants prescribed more safely than controls after receiving the CDSS (0.23 vs. 0.45 [F = 4.24, p < 0.05]). With the CDSS, intervention participants documented more complete assessment of patient gastrointestinal risk from NSAIDs. CONCLUSION: PARTICIPANTS provided with a PDA-based CDSS for NSAID prescribing made fewer unsafe treatment decisions than participants without the CDSS.

Differences in preventive health quality by residency year. Is seniority better?

BACKGROUND: It is assumed that the performance of more senior residents is superior to that of interns, but this has not been assessed objectively. OBJECTIVE: To determine whether adherence to national guidelines for outpatient preventive health services differs by year of residency training. DESIGN: Cross-sectional study. PARTICIPANTS: One hundred twenty Internal Medicine residents, postgraduate year (PGY)- 1 and PGY -2, attending a University Internal Medicine teaching clinic between June 2000 and May 2003. MEASUREMENTS: We studied 6 preventive health care services offered or received by patients by abstracting data from 1,017 patient records. We examined the differences in performance between PGY-1 and PGY-2 residents. RESULTS: Postgraduate year-2 residents did not statistically outperform PGY-1 residents on any measure. The overall proportion of patients receiving appropriate preventive health services for pneumococcal vaccination, advising tobacco cessation, breast and colon cancer screening, and lipid screening was similar across levels of training. PGY-1s outperformed PGY-2s for tobacco use screening (58%, 51%, P = .03). These results were consistent after accounting for clustering of patients within provider and adjusting for patient age, gender, race and insurance, resident gender, and number of visits during the measurement year. CONCLUSIONS: Overall, patients cared for by PGY-2 residents did not receive more outpatient preventive health services than those cared for by PGY-1 residents. Efforts should be made to ensure quality patient care in the outpatient setting for all levels of training.

Re-examination of the cost-effectiveness of surgical versus medical therapy in patients with gastroesophageal reflux disease: the value of long-term data collection.

OBJECTIVES: For patients with reflux esophagitis, long-term therapeutic options include proton pump inhibitor (PPI) therapy and/or antireflux surgery. An earlier cost-effectiveness analysis concluded that at 5 yr, medical therapy was less expensive but similarly effective to fundoplication, but the results were sensitive to estimates on quality of life and long-term medication usage, which were derived from "expert opinion." Recently, data from randomized controlled trials addressing these variables have become available. We have incorporated these new data into a revised Markov model to examine the cost-effectiveness of surgical versus medical therapy in patients with severe reflux esophagitis. METHODS: A Markov simulation model was constructed using specialized software (DATA PRO 4.0, Williamstown, MA). Total expected costs and quality-adjusted life-years were calculated for long-term medical therapy and for laparoscopic Nissen fundoplication. Probabilities were obtained from the medical literature using Medline. Procedural and hospitalization costs used were the average Medicare reimbursements at our institution. Medication costs were the average wholesale price. The analysis was extended over a 10-yr time horizon at a discount rate of 3%. RESULTS: The discounted analysis shows that medical therapy is associated with total costs of 8,798 dollars and 4.59 quality-adjusted life-years, whereas the surgical strategy is more expensive (10,475 dollars) and less effective (4.55 quality-adjusted life-years). The results were robust to most one-way sensitivity analyses. CONCLUSIONS: Long-term medical therapy with proton pump inhibitors is the preferred strategy for patients with gastroesophageal reflux disease and severe esophagitis. Our study highlights the importance of using primary, patient-derived data rather than expert opinion.

American internal medicine in the 21st century: can an Oslerian generalism survive?

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine.

Do local opinion leaders augment hospital quality improvement efforts? A randomized trial to promote adherence to unstable angina guidelines.

BACKGROUND: The influence of an opinion leader intervention on adherence to Unstable Angina (UA) guidelines compared with a traditional quality improvement model was investigated. RESEARCH DESIGN: A group-randomized controlled trial with 2210 patients from 21 hospitals was designed. There were three intervention arms: (1) no intervention (NI); (2) a traditional Health Care Quality Improvement Program (HCQIP); and (3) a physician opinion leader in addition to the HCQIP model (OL). Quality indicators included: electrocardiogram within 20 minutes, antiplatelet therapy within 24 hours and at discharge, and heparin and beta-blockers during hospitalization. Hospitals could determine the specific indicators they wished to target. Potential cases of UA were identified from Medicare claims data. UA confirmation was determined by a clinical algorithm based on data abstracted from medical records. Data analyses included both hospital level analysis (analysis of variance) and patient level analysis (generalized linear models). RESULTS: The only statistically significant postintervention difference in percentage compliant was greater improvement for the OL group in the use of antiplatelet therapy at 24 hours in both hospital level (P = 0.01) and patient level analyses (P <0.05) compared with the HCQIP and NI groups. When analyses were confined to hospitals that targeted specific indicators, compared with the HCQIP hospitals, the OL hospitals showed significantly greater change in percentage compliant postintervention in both antiplatelet therapy during the first 24 hours (20.2% vs. -3.9%, P = 0.02) and heparin (31.0% vs.9.1%, P = 0.05). CONCLUSIONS: The influence of physician opinion leaders was unequivocally positive for only one of five quality indicators. To maximize adherence to best practices through physician opinion leaders, more research on how these physicians influence health care delivery in their organizations will be required.