Observations on the 2016 World Congress on Continuing Professional Development: Advancing Learning and Care in the Health Professions.

The 2016 World Congress on Continuing Professional Development: Advancing Learning and Care in the Health Professions took place in San Diego, California, March 17-19, 2016. Hosts were the Association for Hospital Medical Education (AHME), Alliance for Continuing Education in the Health Professionals (ACEhp), and Society for Academic Continuing Medical Education (SACME). The target audience was the international community working to improve medical (CME), nursing (CNE), pharmacy (CPE), and interprofessional (CIPE) continuing education (CE) and continuing professional development (CPD). Goals included: addressing patients' concerns and needs; advancing global medical and interprofessional health sciences education; utilizing learning to address health disparities; and promoting international cooperation. The five keynote speakers were: patient advocate Alicia Cole ("Why What We Do Matters: The Patients Voice"); linguist Lorelei Lingard ("Myths about Healthcare Teamwork and Their Implications for How We Understand Competence"); futurist and philosopher Alex Jadad ("What Do We Need to Protect at All Costs in the 21st Century?"); ethicist and change agent Zeke Emanuel ("Learn to Change: Teaching Toward a Shifting Healthcare Horizon"); and technology innovator Stephen Downes ("From Individual to Community: The Learning Is in the Doing"). Organizers announced the new Dave Davis Distinguished Award for Excellence in Mentorship in Continuing Professional Development to honor the career of David Davis, MD, in CME/CPD scholarship in Canada, the United States, and beyond. Participants valued the emphasis on interprofessional education and practice, the importance of integrating the patient voice, the effectiveness of flipped classroom methods, and the power of collective competency theories. Attendee-respondents encouraged Congress planners to continue to strive for a broad global audience and themes of international interest.

Reviewing residents' competence: a qualitative study of the role of clinical competency committees in performance assessment.

PURPOSE: Clinical competency committees (CCCs) are now required in graduate medical education. This study examined how residency programs understand and operationalize this mandate for resident performance review. METHOD: In 2013, the investigators conducted semistructured interviews with 34 residency program directors at five public institutions in California, asking about each institution's CCCs and resident performance review processes. They used conventional content analysis to identify major themes from the verbatim interview transcripts. RESULTS: The purpose of resident performance review at all institutions was oriented toward one of two paradigms: a problem identification model, which predominated; or a developmental model. The problem identification model, which focused on identifying and addressing performance concerns, used performance data such as red-flag alerts and informal information shared with program directors to identify struggling residents.In the developmental model, the timely acquisition and synthesis of data to inform each resident's developmental trajectory was challenging. Participants highly valued CCC members' expertise as educators to corroborate the identification of struggling residents and to enhance credibility of the committee's outcomes. Training in applying the milestones to the CCC's work was minimal.Participants were highly committed to performance review and perceived the current process as adequate for struggling residents but potentially not for others. CONCLUSIONS: Institutions orient resident performance review toward problem identification; a developmental approach is uncommon. Clarifying the purpose of resident performance review and employing efficient information systems that synthesize performance data and engage residents and faculty in purposeful feedback discussions could enable the meaningful implementation of milestones-based assessment.

Changing resident test ordering behavior: a multilevel intervention to decrease laboratory utilization at an academic medical center.

Hospital laboratory test volume is increasing, and overutilization contributes to errors and costs. Efforts to reduce laboratory utilization have targeted aspects of ordering behavior, but few have utilized a multilevel collaborative approach. The study team partnered with residents to reduce unnecessary laboratory tests and associated costs through multilevel interventions across the academic medical center. The study team selected laboratory tests for intervention based on cost, volume, and ordering frequency (complete blood count [CBC] and CBC with differential, common electrolytes, blood enzymes, and liver function tests). Interventions were designed collaboratively with residents and targeted components of ordering behavior, including system changes, teaching, social marketing, academic detailing, financial incentives, and audit/feedback. Laboratory ordering was reduced by 8% cumulatively over 3 years, saving $2 019 000. By involving residents at every stage of the intervention and targeting multiple levels simultaneously, laboratory utilization was reduced and cost savings were sustained over 3 years.

Addressing the nation's physician workforce needs: The Society of General Internal Medicine (SGIM) recommendations on graduate medical education reform.

The Graduate Medical Education (GME) system in the United States (US) has garnered worldwide respect, graduating over 25,000 new physicians from over 8,000 residency and fellowship programs annually. GME is the portal of entry to medical practice and licensure in the US, and the pathway through which resident physicians develop the competence to practice independently and further develop their career plans. The number and specialty distribution of available GME positions shapes the overall composition of our national workforce; however, GME is failing to provide appropriate programs that support the delivery of our society's system of healthcare. This paper, prepared by the Health Policy Education Subcommittee of the Society of General Internal Medicine (SGIM) and unanimously endorsed by SGIM's Council, outlines a set of recommendations on how to reform the GME system to best prepare a physician workforce that can provide high quality, high value, population-based, and patient-centered health care, aligned with the dynamic needs of our nation's healthcare delivery system. These recommendations include: accurate workforce needs assessment, broadened GME funding sources, increased transparency of the use of GME dollars, and implementation of incentives to increase the accountability of GME-funded programs for the preparation and specialty selection of their program graduates.

Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program.

PURPOSE: Teaching hospitals strive to engage physicians in quality improvement (QI), and graduate medical education (GME) programs must promote trainee competence in systems-based practice (SBP). The authors developed a QI incentive program that engages residents and fellows, providing them with financial incentives to improve quality while simultaneously gaining SBP experience. In this study, they describe and evaluate success in meeting goals set during the program's first six years. METHOD: During fiscal years (FYs) 2007-2012, QI project goals for all or specific training programs were set collaboratively with residents and fellows at the University of California, San Francisco (UCSF). Data were collected from administrative databases, via chart abstraction, or through independently designed techniques. RESULTS: Approximately 5,275 residents and fellows were eligible and participated in the program. A total of 55 projects were completed. Among the 18 all-program projects, goals were achieved for 11 (61%) in three domains: patient satisfaction, quality/safety, and operation/utilization. Among the 37 program-specific projects, goals were achieved for 28 (76%) in four categories: patient-level interventions, enhanced communication, workflow improvements, and effective documentation. Residents and fellows earned an average of $800 in bonuses/FY for achieving these goals. CONCLUSIONS: Thousands of residents and fellows across disciplines participated in real-life, real-time QI during the program's first six years. Participation provided an experience that may promote SBP competence and resulted in improved quality of care across the UCSF Medical Center. Similar programs may assist teaching hospitals and GME programs in meeting current and future QI and training mandates.

Clinician attitudes about commercial support of continuing medical education: results of a detailed survey.

BACKGROUND: Pharmaceutical and medical device company funding supports up to 60% of accredited continuing medical education (CME) costs in the United States. Some have proposed measures to limit the size, scope, and potential influence of commercial support for CME activities. We sought to determine whether participants at CME activities perceive that commercial support introduces bias, whether this is affected by the amount or type of support, and whether they would be willing to accept higher fees or fewer amenities to decrease the need for such funding. METHODS: We delivered a structured questionnaire to 1347 participants at a series of 5 live CME activities about the impact of commercial support on bias and their willingness to pay additional amounts to eliminate the need for commercial support. RESULTS: Of the 770 respondents (a 57% response rate), most (88%) believed that commercial support introduces bias, with greater amounts of support introducing greater risk of bias. Only 15%, however, supported elimination of commercial support from CME activities, and less than half (42%) were willing to pay increased registration fees to decrease or eliminate commercial support. Participants who perceived bias from commercial support more frequently agreed to increase registration fees to decrease such support (2- to 3-fold odds ratio). Participants greatly underestimated the costs of ancillary activities, such as food, as well as the degree of support actually provided by commercial funding. CONCLUSION: Although the medical professionals responding to this survey were concerned about bias introduced from commercial funding of CME, many were not willing to pay higher fees to offset or eliminate such funding sources.

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.

Continuing medical education in Vietnam: new legislation and new roles for medical schools.

Driven by health care reform and the advent of the private sector in the late 1980s, and by commitments made to the Association of Southeast Asian Nations (ASEAN), Vietnam is faced with a need to increase the regulation and training of its health care professionals. Previously, a diploma from an accredited health professional school was sufficient to practice for a lifetime. Legislation has recently been passed that will institute a licensing system, will require continuing medical education (CME) to maintain the license, and will probably place a large burden on the health professional schools and training institutes to provide CME. Supported by international nongovernmental organizations and foreign universities, the medical universities in Vietnam are responding and are preparing for their new and expanded role.

Commercial influence and learner-perceived bias in continuing medical education.

PURPOSE: To directly examine the relationship between commercial support of continuing medical education (CME) and perceived bias in the content of these activities. METHOD: Cross-sectional study of 213 accredited live educational programs organized by a university provider of CME from 2005 to 2007. A standard question from course evaluations was used to determine the degree to which attendees believed commercial bias was present. Binomial regression models were used to determine the association between course features that may introduce commercial bias and the extent of perceived bias at those CME activities. RESULTS: Mean response rate for attendee evaluations was 56% (SD 15%). Commercial support covered 20%-49% of costs for 45 (21%) educational activities, and > or = 50% of costs for 46 activities (22%). Few course participants perceived commercial bias, with a median of 97% (interquartile range 95%-99%) of respondents stating that the activity they attended was free of commercial bias. There was no association between extent of commercial support and the degree of perceived bias in CME activities. Similarly, perceived bias did not vary for 11 of 12 event characteristics evaluated as potential sources of commercial bias, or by score on a risk index designed to prospectively assess risk of commercial bias. CONCLUSIONS: Rates of perceived bias were low for the vast majority of CME activities in the sample and did not differ by the degree of industry support or other event characteristics. Further study is needed to determine whether commercial influence persisted in more subtle forms that were difficult for participants to detect.

Does health service use in a diabetes management program contribute to health disparities at a facility level? Optimizing resources with demographic predictors.

The objective of this study was to determine if demographic variation in the use of health service resources among type 2 diabetes patients contributes to health disparities. A prospective cohort design was used to analyze differences in health care utilization among 315 adults registered in primary care internal medicine clinics of an academic medical center. Patients were cared for by interdisciplinary teams of internal medicine residents, nurse practitioner students, and pharmacy students supervised by interdisciplinary faculty. A post hoc multivariate repeated measures analysis, using generalized estimating equation (GEE) statistical modeling, was used to determine if age, sex, race, ethnicity, marital status, primary language, and insurance predicted use of health care services (ie, primary care, acute care, emergency department [ED], hospitalization). Medicare/Medicaid-insured patients had an average of 2.49 primary care visits per month (P < .0001) and 75% more ED visits (P < .001) during the study than patients with other insurance types. ED visits for Hispanics grew by a factor of 3.3 compared to non-Hispanics (P < .0001). Females had 52% more hospitalizations than males (P < .05), and Hispanics had 44% fewer hospitalizations than non-Hispanics (P < .05). Analysis of selected health status indicators showed no significant differences for HbA1c, significantly greater likelihood of blood pressure >130/80 with every 5-year increase in age, and significantly greater likelihood of low-density lipoprotein >100 among Medicare/Medicaid-insured patients. Sociodemographic characteristics are predictive of health care services use and suggest that, although equally available to all participants, the use of health care resources vary at the facility level and are independent of diabetes health status outcomes.

Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes.

BACKGROUND: Previous investigations of the effect of the hospitalist model on resource use and patient outcomes have focused on academic medical centers or have used short follow-up periods. OBJECTIVE: To determine the effects of hospitalist care on resource use and patient outcomes and whether these effects change over time. DESIGN: Retrospective cohort study. SETTING: Community-based, urban teaching hospital. PATIENTS: 5308 patients cared for by community or hospitalist physicians in the 2 years after implementation of a voluntary hospitalist service. MEASUREMENTS: Length of stay, costs, 10-day readmission rates, use of consultative services, in-hospital mortality rate, and mortality rate at 30 and 60 days. RESULTS: Patients of hospitalists were younger than those of community physicians (65 years vs. 74 years; P < 0.001) and were more likely to be of black than of white ethnicity (33.3% vs. 17.9%; P < 0.001), have Medicaid insurance (25.1% vs. 10.2%; P < 0.001), and receive intensive care (19.9% vs. 15.8%; P < 0.001). After adjustment in multivariable models, length of stay and costs were not different in the first year of the study. In year 2, patients of hospitalists had shorter stays (0.61 day shorter; P = 0.002) and lower costs ($822 lower; P = 0.002). Over the 2 years of this study, patients of hospitalists had lower risk for death in the hospital (adjusted relative hazard, 0.71 [95% CI, 0.54 to 0.93]) and at 30 and 60 days of follow-up. CONCLUSIONS: A voluntary hospitalist service at a community-based teaching hospital produced reductions in length of stay and costs that became statistically significant in the second year of use. A mortality benefit extending beyond hospitalization was noted in both years. Future investigations are needed to understand the ways in which hospitalists increase clinical efficiency and appear to improve the quality of care.