Faculty Development in Academic Hospital Medicine: a Scoping Review.

This scoping review sought to identify and describe the state of academic faculty development programs in hospital medicine and other specialties. We reviewed faculty development content, structure, metrics of success including facilitators, barriers, and sustainability to create a framework and inform hospital medicine leadership and faculty development initiatives. We completed a systematic search of peer-reviewed literature and searched Ovid MEDLINE ALL (1946 to June 17, 2021) and Embase (via Elsevier, 1947 to June 17, 2021). Twenty-two studies were included in the final review, with wide heterogeneity in program design, program description, outcomes, and study design. Program design included a combination of didactics, workshops, and community or networking events; half of the studies included mentorship or coaching for faculty. Thirteen studies included program description and institutional experience without reported outcomes while eight studies included quantitative analysis and mixed methods results. Barriers to program success included limited time and support for faculty attendance, conflicting clinical commitments, and lack of mentor availability. Facilitators included allotted funding and time for faculty participation, formal mentoring and coaching opportunities, and a structured curriculum with focused skill development supporting faculty priorities. We identified heterogeneous historical studies addressing faculty development across highly variable program design, intervention, faculty targeted, and outcomes assessed. Common themes emerged, including the need for program structure and support, aligning areas of skill development with faculty values, and longitudinal mentoring/coaching. Programs require dedicated program leadership, support for faculty time and participation, curricula focused on skills development, and mentoring and sponsorship.

Characteristics, satisfiers, development needs, and barriers to success for early-career academic hospitalists.

BACKGROUND: Academic hospitalists engage in many non-clinical domains. Success in these domains requires support, mentorship, protected time, and networks. To address these non-clinical competencies, faculty development programs have been implemented. We aim to describe the demographics, job characteristics, satisfiers, and barriers to success of early-career academic hospitalists who attended the Academic Hospitalist Academic (AHA), a professional development conference from 2009 to 2019. METHODS: Survey responses from attendees were evaluated; statistical analyses and linear regression were performed for numerical responses and qualitative coding was performed for textual responses. RESULTS: A total of 965 hospitalists attended the AHA from 2009 to 2019. Of those, 812 (84%) completed the survey. The mean age of participants was 34 years and the mean time in hospitalist practice was 3.2 years. Most hospitalists were satisfied with their job, and teaching and clinical care were identified as the best parts of the job. The proportion of female hospitalists increased from 42.2% in 2009 to 60% in 2019 (p = 0.001). No other demographics or job characteristics significantly changed over the years. Lack of time and confidence in individual skills were the most common barriers identified in both bedside teaching and providing feedback, and providing constructive feedback was an additional challenge identified in giving feedback. CONCLUSIONS: Though early-career hospitalists reported high levels of job satisfaction driven by teaching and clinical care, barriers to success include time constraints and confidence. Awareness of these factors of satisfaction and barriers to success can help shape faculty development curricula for early-career hospitalists.

Using Peer Feedback to Promote Clinical Excellence in Hospital Medicine.

Hospitalists provide a significant amount of direct clinical care in both academic and community hospitals. Peer feedback is a potentially underutilized and low resource method for improving clinical performance, which lends itself well to the frequent patient care handoffs that occur in the practice of hospital medicine. We review current literature on peer feedback to provide an overview of this performance improvement tool, briefly describe its incorporation into multi-source clinical performance appraisals across disciplines, highlight how peer feedback is currently used in hospital medicine, and present practical steps for hospital medicine programs to implement peer feedback to foster clinical excellence among their clinicians.

Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the academic hospitalist taskforce.

Physicians increasingly investigate, work, and teach to improve the quality of care and safety of care delivery. The Society of General Internal Medicine Academic Hospitalist Task Force sought to develop a practical tool, the quality portfolio, to systematically document quality and safety achievements. The quality portfolio was vetted with internal and external stakeholders including national leaders in academic medicine. The portfolio was refined for implementation to include an outlined framework, detailed instructions for use and an example to guide users. The portfolio has eight categories including: (1) a faculty narrative, (2) leadership and administrative activities, (3) project activities, (4) education and curricula, (5) research and scholarship, (6) honors, awards, and recognition, (7) training and certification, and (8) an appendix. The authors offer this comprehensive, yet practical tool as a method to document quality and safety activities. It is relevant for physicians across disciplines and institutions and may be useful as a standalone document or as an adjunct to traditional promotion documents. As the Next Accreditation System is implemented, academic medical centers will require faculty who can teach and implement the systems-based practice requirements. The quality portfolio is a method to document quality improvement and safety activities.

Using Participatory Design to Engage Physicians in the Development of a Provider-Level Performance Dashboard and Feedback System.

PROBLEM DEFINITION: Performance feedback, in which clinicians are given data on select metrics, is widely used in the context of quality improvement. However, there is a lack of practical guidance describing the process of developing performance feedback systems. INITIAL APPROACH: This study took place at the University of California, San Francisco (UCSF) with hospitalist physicians. Participatory design methodology was used to develop a performance dashboard and feedback system. Twenty hospitalist physicians participated in a series of six design sessions and two surveys. Each design session and survey systematically addressed key components of the feedback system, including design, metric selection, data delivery, and incentives. The Capability Opportunity Motivation and Behavior (COM-B) model was then used to identify behavior change interventions to facilitate engagement with the dashboard during a pilot implementation. KEY INSIGHTS, LESSONS LEARNED: In regard to performance improvement, physicians preferred collaboration over competition and internal motivation over external incentives. Physicians preferred that the dashboard be used as a tool to aid in clinical practice improvement and not punitively by leadership. Metrics that were clinical or patient-centered were perceived as more meaningful and more likely to motivate behavior change. NEXT STEPS: The performance dashboard has been introduced to the entire hospitalist group, and evaluation of implementation continues by monitoring engagement and physician attitudes. This will be followed by targeted feedback interventions to attempt to improve performance.

Giant cell myositis associated with metastatic thymoma and granulomatous hypercalcaemia.

Giant cell myositis (GCM) is a rare inflammatory myopathy associated with myasthenia gravis and thymoma. Here, we report on a woman in her late 50s with a history of myasthenia gravis, systemic lupus erythematosus and stage IV thymoma with pleural metastases, who presented with proximal weakness, neuromuscular respiratory failure and hypercalcaemia. She was diagnosed with GCM via muscle biopsy and screened for myocarditis but showed no evidence of myocardial involvement. Her hypercalcaemia was consistent with a granulomatous process, likely driven by her GCM. Her strength gradually improved, and her hypercalcaemia did not recur after treatment with high dose steroids, intravenous immune globulin and plasma exchange. Her course was complicated by several opportunistic infections in the setting of her immunosuppression. Despite the high morbidity associated with GCM, she demonstrated clinical improvement after initiating immunosuppressive therapy and continues to be managed in the outpatient setting.

The oral case presentation: what internal medicine clinician-teachers expect from clinical clerks.

BACKGROUND: The oral case presentation (OCP) is a fundamental communication skill that frequently is taught as part of internal medicine clerkships. However, little is known about the optimal content for an OCP. PURPOSE: We hypothesized that internal medicine clinician-teachers have common expectations regarding OCPs by 3rd-year medical students. METHODS: We administered a 42-item survey to 136 internal medicine faculty members at 5 U.S. medical schools who spent at least 8 weeks as "ward attending" in the 2005-6 academic year, or spent at least 4 weeks as a "ward attending" and had an administrative role in medical education. We asked about the relative importance of 14 potential attributes in a 3rd-year medical student OCP using a 6-point Likert scale. We also asked about their expectations for the length of a new patient presentation. Mean responses from the 5 schools were compared using chi-squared, analysis of variance (ANOVA), and t testing, as appropriate. RESULTS: We received 106 responses (78% response rate). Of our respondents, 45% were hospitalists and 80% self-identified as "clinician-educators." Some aspects of the OCP were rated as more important than others (p<.001) Six items, including aspects of the history of present illness, organization, and structuring the presentation to "make a case" were rated as important or very important by more than 70% of respondents. Fewer than 10% of respondents believed that inclusion of a complete review of systems or detailed family history were important. Few differences were seen between institutions. Faculty expected that OCPs should take 9.9±5.4 min, with faculty at one institution having significantly different expectations than all others (15.9±6.4 min vs. 7.8±2.8, p<.001). CONCLUSIONS: Internal medicine clinician teachers from 5 U.S. medical schools share common expectations for OCPs.

The HCAP gap: differences between self-reported practice patterns and published guidelines for health care-associated pneumonia.

BACKGROUND: Health care-associated pneumonia (HCAP) is prevalent among hospitalized patients. In contrast to community-acquired pneumonia (CAP), patients with HCAP are at increased risk for multidrug-resistant organisms, and appropriate initial antibiotic therapy is associated with reduced mortality. METHODS: An online survey was distributed to faculty and housestaff at 4 academic medical centers. The survey required respondents to choose initial antibiotic therapy for 9 hypothetical pneumonia cases (7 cases of HCAP and 2 cases of CAP). Answers were considered correct if the antibiotic regimen chosen was consistent with published guidelines. In addition, physicians rated their knowledge of current guidelines, as well as their level of agreement with guideline recommendations. RESULTS: Surveys were sent to 1313 physicians with a response rate of 65% (n = 855). Respondents included physicians in the following categories: hospital medicine/internal medicine, 60%; emergency medicine, 25%; and critical care, 13%. Respondents selected guideline-concordant antibiotic regimens 78% of the time for CAP, but only 9% of the time for HCAP. Because mean scores for HCAP questions were extremely low (mean, 0.63 correct answers out of 7), differences in performance between groups were too small to be meaningful. Despite their poor performance, 71% of the respondents stated that they are aware of published guidelines for HCAP, and 79% stated that they agree with and practice according to the guidelines. CONCLUSIONS: In this survey, physicians reported they were aware of, agreed with, and practiced according to published pneumonia guidelines; however, the overwhelming majority did not choose guideline-concordant therapy when tested.

Expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors.

BACKGROUND: Little is known about the expectations of undergraduate internal medicine educators for oral case presentations (OCPs). OBJECTIVE: We surveyed undergraduate internal medicine educational leaders to determine the degree to which they share the same expectations for oral case presentations. SUBJECTS: Participants were institutional members of the Clerkship Directors of Internal Medicine (CDIM). DESIGN: We included 20 questions relating to the OCP within the CDIM annual survey of its institutional members. We asked about the relative importance of specific attributes in a third-year medical student OCP of a new patient as well as its expected length. Percentage of respondents rating attributes as "very important" were compared using chi-squared analysis. RESULTS: Survey response rate was 82/110 (75%). Some attributes were more often considered very important than others (p < .001). Eight items, including aspects of the history of present illness, organization, a directed physical exam, and a prioritized assessment and plan focused on the most important problems, were rated as very important by >50% of respondents. Respondents expected the OCP to last a median of 7 minutes. CONCLUSIONS: Undergraduate internal medicine education leaders from a geographically diverse group of North American medical schools share common expectations for OCPs which can guide instruction and evaluation of this skill.

Twelve tips for presenting a clinical problem solving exercise.

BACKGROUND: Lectures are moderately effective for teaching medical knowledge but generally fail at promoting clinical reasoning. In a clinical problem solving (CPS) conference, a clinician is presented an unknown medical case in a stepwise fashion. These popular conferences highlight clinical reasoning and foster active learning to a greater degree than lecture-based education. AIM: In the absence of literature which addresses the organization of these conferences, we present a guide for the teacher (case presenter) to maximize the session's educational value. METHODS: Practical issues for case selection, preparation, and presentation are addressed. The predominant theme is to retain an emphasis on real-time reasoning and to minimize the artificial nature of solving an unknown case from presented material rather than a live patient. CONCLUSIONS: The successful execution of the CPS engages both the audience and the discussant in real-time problem solving and relies upon the tenants of experiential learning and clinical reasoning rather than the traditional structure of the medical case presentation.

Update in Hospital Medicine: Practical Lessons from Current Literature.

BACKGROUND: Hospital medicine continues to grow in workforce, clinical scope, and academic inquiry. This article provides a summary of recent high-impact publications for busy clinicians who provide care to hospitalized adults. METHODS: Authors reviewed articles that were published between March 2017 and March 2018 for the Update in Hospital Medicine presentations at the 2018 Society of Hospital Medicine and Society of General Internal Medicine annual meetings. Nine of the 29 articles presented were selected for this review based on quality and potential to influence practice. RESULTS: The following key insights were gained: (1) the perioperative continuation of aspirin in patients with previous percutaneous intervention is beneficial; (2) delaying hip fracture surgery beyond a 24-hour window increases complications; (3) oral antibiotics may be effective treatment for select bloodstream infections; (4) pulmonary embolism may not be as common a cause of syncope as previously suggested; (5) balanced intravenous fluids and normal saline are similar with respect to hospital-free days but a difference exists in renal events at 30 days favoring balanced crystalloids; (6) speaker introductions may reveal gender bias in academic medicine; (7) edoxaban is a reasonable choice for the treatment of venous thromboembolism in cancer; (8) high-flow nasal cannula reduces the need for intubation in respiratory failure when compared with usual oxygen therapy and noninvasive positive pressure ventilation; and (9) diagnostic errors in spinal epidural abscess lead to delays and morbidity. CONCLUSIONS: This research provides insight into how we can approach common medical problems in the care of hospitalized adults. The selected works have the potential to change or confirm current practices.

Hospital Medicine Update: High-Impact Literature from March 2018 to April 2019.

To assist busy hospital medicine clinicians, we summarized 10 impactful articles from last year. The authors reviewed articles published between March 2018-April 2019 for the Hospital Medicine Updates at the Society of Hospital Medicine and the Society of General Internal Medicine Annual Meetings. The authors voted to select 10 of 30 presented articles based on quality and clinical impact for this summary. The key findings include: (1) Vancomycin or fidaxomicin are the first-line treatment for initial Clostridioides difficile infection; (2) Unnecessary supplemental oxygen is linked to increased mortality; aim for a target oxygen saturation of 90%-94% in most hospitalized patients; (3) Stigmatizing language in medical records impacts physician trainees' attitudes and pain management practices; (4) Consider ablation for atrial fibrillation in patients with heart failure; (5) Patients with opioid use disorder should be offered buprenorphine or methadone therapy; (6) Apixaban is safe and may be preferable over warfarin in patients with atrial fibrillation and end-stage kidney disease; (7) It is probably safe to discontinue antimethicillin-resistant Staphylococcus aureus (MRSA) coverage in patients with hospital-acquired pneumonia who are improving and have negative cultures; (8) Selected patients with left-sided endocarditis (excluding MRSA) may switch from intravenous (IV) to oral antibiotics if they are clinically stable after 10 days; (9) Oral antibiotics may be equivalent to IV antibiotics in patients with joint and soft tissue infections; (10) A history-electrocardiogram-age-risk factors-troponin (HEART) score ≥4 is a reliable threshold for determining the patients who are at risk for short-term major adverse cardiac events and may warrant further evaluation.

A multidisciplinary teamwork training program: the Triad for Optimal Patient Safety (TOPS) experience.

INTRODUCTION: Communication and teamwork failures are a common cause of adverse events. Residency programs, with a mandate to teach systems-based practice, are particularly challenged to address these important skills. AIM: To develop a multidisciplinary teamwork training program focused on teaching teamwork behaviors and communication skills. SETTING: Internal medicine residents, hospitalists, nurses, pharmacists, and all other staff on a designated inpatient medical unit at an academic medical center. PROGRAM DESCRIPTION: We developed a 4-h teamwork training program as part of the Triad for Optimal Patient Safety (TOPS) project. Teaching strategies combined didactic presentation, facilitated discussion using a safety trigger video, and small-group scenario-based exercises to practice effective communication skills and team behaviors. Development, planning, implementation, delivery, and evaluation of TOPS Training was conducted by a multidisciplinary team. PROGRAM EVALUATION: We received 203 evaluations with a mean overall rating for the training of 4.49 +/- 0.79 on a 1-5 scale. Participants rated the multidisciplinary educational setting highly at 4.59 +/- 0.68. DISCUSSION: We developed a multidisciplinary teamwork training program that was highly rated by all participating disciplines. The key was creating a shared forum to learn about and discuss interdisciplinary communication and teamwork.

Strategies for success: A PDSA analysis of three QI initiatives in critical care.

BACKGROUND: Implementation of evidence-based quality improvement (QI) initiatives is not without its challenges. Recent experience in the design, implementation, and evaluation of three QI initiatives at the University of California, San Francisco Medical Center (UCSF) suggests lessons learned that may be generalizable to other QI initiatives. INITIATIVES: Between December 2002 and May 2006, a ventilator bundle of care and a tight glycemic control (TGC) protocol were implemented in the intensive care units (ICUs), and early goal-directed therapy (EGDT) for patients with severe sepsis or septic shock was implemented in the ICUs and emergency department. The initiatives were selected on the basis of the magnitude of the problem, strength of the evidence regarding associated reductions in morbidity and mortality in the critically ill, and cost-effectiveness. LESSONS LEARNED: A number of challenges in QI processes and strategies for success were identified via retrospective analysis within the construct of the Plan-Do-Study-Act model, representing a novel use of the model. Pitfalls most commonly occurred in the planning stage. Suggested strategies for success include using an interdisciplinary team, selecting a champion, securing additional resources, identifying specific goals and providing feedback on progress, using work-flow analyses and stepwise implementation and/or pilot testing, creating standard work, eliciting feedback from staff, and celebrating successes. The knowledge gained from these initiatives has been disseminated at UCSF, and the initiatives have helped to raise general awareness regarding the importance of quality. CONCLUSIONS: The ventilator bundle of care, TGC, and EGDT are still in use at UCSF, with modification of the initiatives occurring as new evidence becomes available.

Training Residents in Hospital Medicine: The Hospitalist Elective National Survey.

As the field of hospital medicine expands, internal medicine residency programs can play a role in preparing future hospitalists. To date, little is known of the prevalence and characteristics of hospitalist-focused resident rotations. We surveyed the largest 100 Internal Medicine Residency Programs to better understand the prevalence, objectives, and structure of hospitalist-focused rotations in the United States. Residency leaders from 82 programs responded (82%). The prevalence of hospitalist-focused rotations was 50% (41/82) with an additional 9 programs (11%) planning to start one. Of these 41 rotations, 85% were elective rotations and 15% were mandatory rotations. Rotations involved clinical responsibilities, and most programs incorporated nonclinical curricular activities such as teaching, research, and work on quality improvement and patient safety. Respondents noted that their programs promoted autonomy, mentorship, and "real-world" hospitalist experience. Hospitalist-focused rotations may supplement traditional inpatient rotations and teach skills that facilitate the transition from residency to a career in hospital medicine.

Update in Hospital Medicine: Practical Lessons from the Literature.

BACKGROUND: Hospital Medicine has a widening scope of practice. This article provides a summary of recent highimpact publications for busy clinicians who provide care to hospitalized adults. METHODS: The authors reviewed articles published between March 2016 and March 2017 for the Update in Hospital Medicine presentations at the 2017 Society of Hospital Medicine and Society of General Internal Medicine annual meetings. Nine of the 20 articles presented were selected for this review based on the article quality and potential to influence practice. RESULTS: The key insights gained include: pulmonary embolism may be a more common cause of syncope and acute exacerbation of COPD than previously recognized; nonthoracic low-tesla MRI is safe following a specific protocol for patients with cardiac devices implanted after 2001; routine inpatient blood cultures for fever are of a low yield with a false positive rate similar to the true positive rate; chronic opioid use after surgery occurs more frequently than in the general population; high-sensitivity troponin and a negative ECG performed 3 hours after an episode of chest pain can rule out acute myocardial infarction; sitting at patients' bedsides enhances patients' perception of provider communication; 5 days of antibiotics for community-acquired pneumonia is equivalent to longer courses; oral proton pump inhibitors (PPI) are as effective as IV PPIs after an esophagogastroduodenoscopy (EGD) for the treatment of bleeding peptic ulcers. CONCLUSIONS: Recent research provides insight into how we approach common medical problems in the care of hospitalized adults. These articles have the potential to change or confirm current practices.

A Prescription for Note Bloat: An Effective Progress Note Template.

BACKGROUND: United States hospitals have widely adopted electronic health records (EHRs). Despite the potential for EHRs to increase efficiency, there is concern that documentation quality has suffered. OBJECTIVE: To examine the impact of an educational session bundled with a progress note template on note quality, length, and timeliness. DESIGN: A multicenter, nonrandomized prospective trial. SETTING: Four academic hospitals across the United States. PARTICIPANTS: Intern physicians on inpatient internal medicine rotations at participating hospitals. INTERVENTION: A task force delivered a lecture on current issues with documentation and suggested that interns use a newly designed best practice progress note template when writing daily progress notes. MEASUREMENTS: Note quality was rated using a tool designed by the task force comprising a general impression score, the validated Physician Documentation Quality Instrument, 9-item version (PDQI-9), and a competency questionnaire. Reviewers documented number of lines per note and time signed. RESULTS: Two hundred preintervention and 199 postintervention notes were collected. Seventy percent of postintervention notes used the template. Significant improvements were seen in the general impression score, all domains of the PDQI-9, and multiple competency items, including documentation of only relevant data, discussion of a discharge plan, and being concise while adequately complete. Notes had approximately 25% fewer lines and were signed on average 1.3 hours earlier in the day. CONCLUSIONS: The bundled intervention for progress notes significantly improved the quality, decreased the length, and resulted in earlier note completion across 4 academic medical centers.

Using the Electronic Health Record to Identify Educational Gaps for Internal Medicine Interns.

BACKGROUND: An important component of internal medicine residency is clinical immersion in core rotations to expose first-year residents to common diagnoses. OBJECTIVE: Quantify intern experience with common diagnoses through clinical documentation in an electronic health record. METHODS: We analyzed all clinical notes written by postgraduate year (PGY) 1, PGY-2, and PGY-3 residents on medicine service at an academic medical center July 1, 2012, through June 30, 2014. We quantified the number of notes written by PGY-1s at 1 of 3 hospitals where they rotate, by the number of notes written about patients with a specific principal billing diagnosis, which we defined as diagnosis-days. We used the International Classification of Diseases 9 (ICD-9) and the Clinical Classification Software (CCS) to group the diagnoses. RESULTS: We analyzed 53 066 clinical notes covering 10 022 hospitalizations with 1436 different ICD-9 diagnoses spanning 217 CCS diagnostic categories. The 10 most common ICD-9 diagnoses accounted for 23% of diagnosis-days, while the 10 most common CCS groupings accounted for more than 40% of the diagnosis-days. Of 122 PGY-1s, 107 (88%) spent at least 2 months on the service, and 3% were exposed to all of the top 10 ICD-9 diagnoses, while 31% had experience with fewer than 5 of the top 10 diagnoses. In addition, 17% of PGY-1s saw all top 10 CCS diagnoses, and 5% had exposure to fewer than 5 CCS diagnoses. CONCLUSIONS: Automated detection of clinical experience may help programs review inpatient clinical experiences of PGY-1s.