Teaming up to take down costs.

By linking specialty-specific clinical teams with supply chain experts, Saint Luke's Health System established cost-containment strategies that align with clinical pathways and create new leverage with vendors. Since the initiative launched in January 2013, Saint Luke's has reduced medical supply costs by more than $6 million. In several instances, physicians have led the way in formulating cost-cutting ideas that exceeded the expectations of supply chain administrators.

Characteristics of CPOE systems and obstacles to implementation that physicians believe will affect adoption.

BACKGROUND: Computerized Physician Order Entry (CPOE) has the potential to decrease medical errors and improve quality. Our health system plans to implement CPOE in response to the ARRA HITECH Act. OBJECTIVES: To determine (A) physicians' projections of the most important characteristics of a CPOE system that will affect their willingness to adopt CPOE, and (B) the obstacles they foresee in adopting CPOE. METHODS: All members of our health system's physician quality organization were invited to participate in a confidential survey. RESULTS: Two hundred twenty-four of 549 (41%) recipients responded to the survey. Respondents ranked "disruption in my work routine" (72%) and "improve efficiency in placing orders" (63%) as the two most important characteristics that would affect their utilization of CPOE. They believed CPOE would enable orders to be placed more efficiently (3.3, sd = 1.2), carried out rapidly (3.4, sd = 0.9), and have fewer errors (3.7, sd = 0.9). The most commonly cited obstacles to CPOE implementation were: Efficiency-Inefficiency (23%), Hardware Availability (12.7%), Computer Restrictions (10.8%), Training (8.8%), Simplicity - Ease of Use (8.5%), and Physician Buy-in (8.1%). CONCLUSIONS: The majority of physicians believed CPOE would lead to a reduction of medical errors and more efficient patient care. However, physicians are highly concerned with how CPOE will affect their own work efficiency.

The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour & improve safety.

BACKGROUND: Prescribing alerts of an electronic health record are meant to be protective, but often are disruptive to providers. Our goal was to assess the effectiveness of interruptive medication-prescriber alerts in changing prescriber behaviour and improving patient outcomes in ambulatory care settings via computerised provider order entry (CPOE) systems. METHODS: A standardised search strategy was developed and applied to the following key bibliographical databases: PubMed, Embase, CINAHL and The Cochrane Library. Non-comparison studies and studies on non-interrupted alerts were eliminated. We developed a standardised data collection form and abstracted data that included setting, study design, category of intervention alert and outcomes measured. The search was completed in August 2018 and repeated in November of 2019 and of 2020 to identify any new publications during the time lapse. RESULTS: Ultimately, nine comparison studies of triggered alerts were identified. Each studied at least one outcome measure illustrating how the alert affected prescriber decision-making. Provider behaviour was influenced in the majority, with most noting a positive change. Alerts decreased pharmaceutical costs, moved medications toward preferred medications tiers and steered treatments toward evidence-based choices. They also decreased prescribing errors. Clinician feedback, rarely solicited, expressed frustration with alerts creating a time delay. CONCLUSION: The current evidence shows a clear indication that many categories of alerts are effective in changing prescriber behaviour. However, it is unclear whether these behavioural changes lead to improved patient outcomes. Despite the rapid transition to CPOE use for patient care, there are few rigorous studies of triggered alerts and how workflow interruptions impact patient outcomes and provider acceptance.

What do you do when your loved one is ill? The line between physician and family member.

Conventional wisdom and professional ethics generally dictate that physicians should avoid doctoring family members because of potential conflicts of interest. Nevertheless, cross-sectional surveys find that the practice is commonplace. Physicians have unique opportunities to influence their family member's care because they possess knowledge and status within the health care system; however, when physicians participate in the care of family members, they must not lose objectivity and confuse their personal and professional roles. Because health care systems are complicated, medical information is difficult to understand, and medical errors are common, it can be a great relief for families to have someone "on the inside" who is accessible and trustworthy. Yet, the benefits of becoming involved in a loved one's care are accompanied by risks, especially when a physician takes action that a nonphysician would be incapable of performing. Except for convenience, most if not all of the benefits of getting involved can be realized by physician-family members acting as a family member or an advocate rather than as a physician. Rules about what is or what is not appropriate for physician-family members are important but insufficient to guide physicians in every circumstance. Physician-family members can ask themselves, "What could I do in this situation if I did not have a medical degree?" and consider avoiding acts that require a medical license.

Humor in intern retreats: scrubbing away the blues.

Humor in everyday practice has been shown to reduce work stress and increase efficiency. We aimed to study the effect of humor on interns for which we employed humor in one of the intern retreats and later asked the interns to rate the value of each retreat. Pre- and post- retreat mood states were also surveyed. The majority of interns recommended that humorous intern retreats be used in the coming years. A trend towards improvement in depression scores was also noticed.

A Conversation About the Role of Humiliation in Teaching: The Ugly, the Bad, and the Good.

In this Invited Commentary, the authors identify the ugly, the bad, and the good in teaching in medical education, based on their experiences as medical students and then educators. They reflect on the mistreatment they endured during medical school and its impact on their education and their careers as educators. They also highlight those exemplars from their training who role modeled the type of physician and educator they want to be. The authors conclude by describing the elements of learner-centered education that they practice, which may be helpful for others to consider, and call on their fellow educators to end the practice of humiliating learners by moving away from a controlled-motivation model toward an autonomy-supportive approach to education.

The state of evaluation in internal medicine residency.

BACKGROUND: There are no nationwide data on the methods residency programs are using to assess trainee competence. The Accreditation Council for Graduate Medical Education (ACGME) has recommended tools that programs can use to evaluate their trainees. It is unknown if programs are adhering to these recommendations. OBJECTIVE: To describe evaluation methods used by our nation's internal medicine residency programs and assess adherence to ACGME methodological recommendations for evaluation. DESIGN: Nationwide survey. PARTICIPANTS: All internal medicine programs registered with the Association of Program Directors of Internal Medicine (APDIM). MEASUREMENTS: Descriptive statistics of programs and tools used to evaluate competence; compliance with ACGME recommended evaluative methods. RESULTS: The response rate was 70%. Programs were using an average of 4.2-6.0 tools to evaluate their trainees with heavy reliance on rating forms. Direct observation and practice and data-based tools were used much less frequently. Most programs were using at least 1 of the Accreditation Council for Graduate Medical Education (ACGME)'s "most desirable" methods of evaluation for all 6 measures of trainee competence. These programs had higher support staff to resident ratios than programs using less desirable evaluative methods. CONCLUSIONS: Residency programs are using a large number and variety of tools for evaluating the competence of their trainees. Most are complying with ACGME recommended methods of evaluation especially if the support staff to resident ratio is high.

Perceived, actual, and desired knowledge regarding Medicare billing and reimbursement. A national needs assessment survey of internal medicine residents.

BACKGROUND: Economics and reimbursement have become a daily part of practicing physicians' lives. Yet, few internal medicine (IM) programs have offered formal curricula during residency about practice management or economics. OBJECTIVE: To determine perceived, desired, and actual knowledge of Medicare billing and reimbursement among residents compared with community-based General Internists. DESIGN AND PARTICIPANTS: Cross-sectional needs assessment survey of community and university-based second-year IM residents from 4 geographic regions of the United States. RESULTS: One hundred and thirty-three second-year IM residents completed the questionnaire. Residents rated their level of knowledge about Medicare as a 2.0 (SD=0.9) on a Likert scale (1="very low," 5="very high"). Residents agreed that Medicare reimbursement should be taught in residency with a score of 4.0 (SD=1.1; 1="strongly disagree," 5="strongly agree" SD=1.1). On the knowledge assessment portion of the questionnaire, residents scored significantly lower than a group of general IM physicians who completed the same questions (percent correct=41.8% vs 59.0%, P<.001). Residents' scores correlated with their self-assessed level of knowledge (P=.007). CONCLUSIONS: Our study demonstrates that second year IM residents feel they have a low level of knowledge regarding outpatient Medicare billing, and have a lower test score than practicing Internists to back up their feelings. The residents also strongly agree that they do not receive enough education about Medicare reimbursement, and believe it should be a requirement in residency training.

A time to be promoted. The Prospective Study of Promotion in Academia (Prospective Study of Promotion in Academia).

OBJECTIVE: The study's objectives were to determine (1) the rate at which department of medicine faculty in the United States are promoted, (2) if clinician-educators (CEs) are promoted to Associate Professor at the same rate as clinician-investigators (CIs), and (3) the variables that predict promotion. METHODS: The Prospective Study of Promotion in Academia was a part-retrospective, part-prospective (from 2000 to 2003) cohort study. Six-hundred and four Internal Medicine junior faculty across the United States who had been registered as new appointees with the Association of American Medical Colleges in 1995 were invited to participate. Twenty-one percent of these had already left their institution when the study began. One hundred and eighty-three Internal Medicine faculty from 87 institutions in 35 states enrolled. The main outcome measure was the time from appointment as Assistant Professor to promotion to Associate Professor. RESULTS: Follow-up was complete for all 183 faculty. Among the faculty that achieved promotion, the estimated median time to promotion was 6.0 years (95% Conf. Int.=5.8 to 6.2). The unadjusted sixth-year promotion rate for CEs was 16%, while for CIs it was 26% (P=.002). Independent negative predictors of promotion included low amount of research time (Hazard Ratio [HR] =0.3, 95% Conf. Int.=0.2 to 0.5), having a manuscript review service (HR=0.4, 95% Conf. Int.=0.2 to 0.7), never meeting with Chairman/Chief about promotion (HR=0.4, 95% Conf. Int.=0.2 to 0.7), low job satisfaction (HR=0.5, 95% Conf. Int.=0.3 to 0.9), and working in the Northeast (HR=0.6, 95% Conf. Int.=0.4 to 1.1). Positive predictors included making between 130 dollars and 149,000 dollars per year (HR=1.9, 95% Conf. Int.=1.1 to 3.4), working more than 60 h/wk (HR=1.9, 95% Conf. Int.=1.1 to 3.0), having a career mentor available (HR=1.8, 95% Conf. Int.=1.1 to 2.9), and having access to a grant office (HR=1.6, 95% Conf. Int.=1.0 to 2.6). CONCLUSION: CEs and CIs appear to be promoted at different rates. The characteristics that are independently associated with earlier promotion may be helpful for institutions and individual faculty that are committed to achieving promotion efficiently.

Personal growth during internship: a qualitative analysis of interns' responses to key questions.

BACKGROUND: During clinical training, house officers frequently encounter intense experiences that may affect their personal growth. The purpose of this study was to explore processes related to personal growth during internship. DESIGN: Prospective qualitative study conducted over the course of internship. PARTICIPANTS: Thirty-two postgraduate year (PGY)-1 residents from 9 U.S. internal medicine training programs. APPROACH: Every 8 weeks, interns responded by e-mail to an open-ended question related to personal growth. Content analysis methods were used to analyze the interns' writings to identify triggers, facilitators, and barriers related to personal growth. RESULTS: Triggers for personal growth included caring for critically ill or dying patients, receiving feedback, witnessing unprofessional behavior, experiencing personal problems, and dealing with the increased responsibility of internship. Facilitators of personal growth included supportive relationships, reflection, and commitment to core values. Fatigue, lack of personal time, and overwhelming work were barriers to personal growth. The balance between facilitators and barriers may dictate the extent to which personal growth occurs. CONCLUSIONS: Efforts to support personal growth during residency training include fostering supportive relationships, encouraging reflection, and recognizing interns' core values especially in association with powerful triggers.

Motivating factors for academic physicians within departments of medicine.

OBJECTIVE: To understand what motivates academic physicians at a time when physician dissatisfaction is prevalent. SUBJECTS AND METHODS: Of a cohort of 480 physician faculty members (identified from the Association of American Medical Colleges faculty roster) hired at the assistant professor level, 183 were monitored prospectively for a characterization of their success in achieving promotion. In mid-2001, follow-up data were collected about the factors that physicians described as motivating in their work. We conducted this study to understand the differences in motivators between clinician-educators and cliniclan-investigators and between male and female physicians, as well as to validate a previously used instrument developed to assess motivation and occupational values. RESULTS: Of 183 physicians monitored, 144 (79%) responded to an interim follow-up questionnaire. Factor analysis revealed that physicians' occupational motivators could be grouped statistically into 3 factors: self-expression, helping others, and extrinsic rewards. Compared with clinician-educators, clinician-investigators were more motivated in their current work by having the ability to express themselves (composite factor score, 4.30 vs 3.84; P<.001). Clinician-investigators also rated 4 of the 6 items within the factor of self-expression as being significantly stronger motivators for them than did the clinician-educators. Compared with male physicians, female physicians Indicated they were more motivated by helping others (composite factor score, 4.18 vs 3.89; P=.03). CONCLUSIONS: Factors that motivate physicians appear to be different for clinician-investigators and clinician-educators as well as for male and female physicians. Understanding the inspiration for physicians may help medical leadership to better motivate and relate to their physician workforce.

Determining the predictors of internal medicine residency accreditation: what they do (not what they say).

PURPOSE: The Accreditation Council for Graduate Medical Education and the Residency Review Committee for Internal Medicine (RRC-IM) evaluate internal medicine residency programs using a list of 301 program requirements. The authors investigated which requirements, program demographics, and site-visitor characteristics were the strongest predictors of accreditation. METHOD: The authors surveyed the program directors of all 405 accredited internal medicine residency programs in February 1998, obtaining data on the duration of the accreditation process, site visitors, and number and quality of citations. They also requested a copy of the notification letter containing citations and length of time until the next accreditation site visit (cycle length). RESULTS: A total of 217 responses (54%) was received. The mean cycle length was 3.0 years, and the accreditation process averaged 14.5 months. Smaller programs had a shorter average cycle length. Site visitors were reported to be prepared and professional overall. However, site visitors with the lowest evaluations by program directors were associated with shorter cycle lengths. Four program characteristics and program citations accounted for 60% of the variation in cycle length: total number of citations in the notification letter, percentage of graduates passing the American Board of Internal Medicine Certifying Examination, inadequate demonstration of resident scholarship, and inadequate ambulatory care experience. CONCLUSION: The authors devised an independent mechanism for determining the duration of the RRC-IM review process, influence of program demographics on the process, influence of site visitors on the accreditation action, and program requirements having the greatest effect on cycle length.

Benchmarks of support in internal medicine residency training programs.

PURPOSE: To identify benchmarks of financial and staff support in internal medicine residency training programs and their correlation with indicators of quality. METHOD: A survey instrument to determine characteristics of support of residency training programs was mailed to each member program of the Association of Program Directors of Internal Medicine. Results were correlated with the three-year running average of the pass rates on the American Board of Internal Medicine certifying examination using bivariate and multivariate analyses. RESULTS: Of 394 surveys, 287 (73%) were completed: 74% of respondents were program directors and 20% were both chair and program director. The mean duration as program director was 7.5 years (median = 5), but it was significantly lower for women than for men (4.9 versus 8.1; p =.001). Respondents spent 62% of their time in educational and administrative duties, 30% in clinical activities, 5% in research, and 2% in other activities. Most chief residents were PGY4s, with 72% receiving compensation additional to base salary. On average, there was one associate program director for every 33 residents, one chief resident for every 27 residents, and one staff person for every 21 residents. Most programs provided trainees with incremental educational stipends, meals while oncall, travel and meeting expenses, and parking. Support from pharmaceutical companies was used for meals, books, and meeting expenses. Almost all programs provided meals for applicants, with 15% providing travel allowances and 37% providing lodging. The programs' board pass rates significantly correlated with the numbers of faculty fulltime equivalents (FTEs), the numbers of resident FTEs per office staff FTEs, and the numbers of categorical and preliminary applications received and ranked by the programs in 1998 and 1999. Regression analyses demonstrated three independent predictors of the programs' board pass rates: number of faculty (a positive predictor), percentage of clinical work performed by the program director (a negative predictor), and financial support from pharmaceutical companies (also a negative predictor). CONCLUSIONS: These results identify benchmarks of financial and staff support provided to internal medicine residency programs. Some of these benchmarks are correlated with board pass rate, an accepted indicator of quality in residency training. Program directors and chairs can use this information to identify areas that may benefit from enhanced financial and administrative support.

Comparing practice differences of residency graduates: implications for curricular change.

OBJECTIVE: To document and assess differences in the practice experiences and practice patterns of graduates from two similar sized but regionally separated community-based internal medicine residency programs. RESULTS: Sixty percent responded to the survey. Responses from graduates practicing general internal medicine were used in the analyses (Wichita n = 20; Baystate n = 23). Only graduates from Wichita were in solo practice (15%). Baystate graduates had a significantly higher percentage of HMO patients (32% vs. 17%, p < .05). A higher percentage of Kansas respondents worked in a community with a population of less than 50,000 (55% vs. 26%, p = .052). Of 28 components of a residency curriculum, 7 were considered significantly more important to daily practice by Kansas respondents than by Baystate respondents: Critical Care, Dermatology, Gastroenterology, Nephrology, Neurology, Occupational Medicine, and Rheumatology. Kansas respondents performed on average significantly more procedures than Massachusetts respondents in the last year in 6 of 16 procedures: bone marrow biopsy, exercise stress tests, flexible sigmoidoscopy, liquid nitrogen, skin biopsy, and thoracentesis. The procedures of skin biopsy, stress testing, and the curricula of dermatology, nephrology, neurology and rheumatology remained significantly different when controlled for the size of the community population (<50,000). Wichita graduates scored higher on the practice intensity measure than Baystate graduates. CONCLUSIONS: We have documented differences in the importance of particular curricula, procedures, and practice intensity likely related to the community population in which residency graduates practice. Understanding the needs of graduates and incorporating this information into existing rotations or new initiatives is integral to the ongoing development of residency curricula.