Providing Structured Real-Time Feedback on Postdischarge Outcomes Using Electronic Health Record Data.

OBJECTIVES: Most trainees do not receive information about postdischarge outcomes, despite the importance of external feedback for accurate self-assessment and improvement in discharge planning skills. We aimed to design an intervention to foster reflection and self-assessment by trainees regarding how they can improve transitions of care with minimal investment of program resources. METHODS: We developed a low-resource session delivered near the end of an internal medicine inpatient rotation. Faculty, medical students, and internal medicine residents reviewed and reacted to postdischarge outcomes of their patients, explored understanding of the reasons for these outcomes, and developed goals for future practice. The intervention required minimal resources given that it was conducted during scheduled teaching time, did not require additional staff, and used already available data. Forty internal medicine resident and medical student participants completed pre- and postintervention surveys that evaluated their understanding of causes for poor patient outcomes, sense of responsibility for postdischarge outcomes, degree of self-reflection, and goals for future practice. RESULTS: Trainee understanding of the causes for poor patient outcomes was significantly different in several areas after completing the session. Trainees were less likely to believe that their responsibility for patients ends at the time of discharge, indicating an increase in sense of responsibility for postdischarge outcomes. After the session, 52.6% of trainees planned to change their approach to discharge planning, and 57.1% of attending physicians planned to change their approach to discharge planning with trainees. Through free-text responses, trainees noted that the intervention facilitated reflection and discussion about discharge planning and led to the development of goals to adopt specific behaviors for future practice. CONCLUSIONS: Meaningful information about postdischarge outcomes from the electronic health record can be used to provide feedback to trainees in a brief, low-resource session during an inpatient rotation. This feedback significantly affects trainee sense of responsibility for and understanding of postdischarge outcomes, which may lead to improved trainee ability to orchestrate transitions of care.

Chief resident behaviors that lead to effective morning reports, a multisite qualitative study.

BACKGROUND: Morning report is a fundamental component of internal medicine training and often represents the most significant teaching responsibility of Chief Residents. We sought to define Chief Resident behaviors essential to leading a successful morning report. METHODS: In 2016, we conducted a multi-site qualitative study using key informant interviews of morning report stakeholders. 49 residents, Chief Residents, and faculty from 4 Internal Medicine programs participated. Interviews were analyzed and coded by 3 authors using inductive reasoning and thematic analysis. A preliminary code structure was developed and expanded in an iterative process concurrent with data collection until thematic sufficiency was reached and a final structure was established. This final structure was used to recode all transcripts. RESULTS: We identified four themes of Chief Resident behaviors that lead to a successful morning report: report preparation, delivery skills, pedagogical approaches, and faculty participation. Preparation domains include thoughtful case selection, learning objective development, content editing, and report organization. Delivery domains include effective presentation skills, appropriate utilization of technology, and time management. Pedagogical approach domains include learner facilitation techniques that encourage clinical reasoning while nurturing a safe learning environment, as well as innovative teaching strategies. Moderating the involvement of faculty was identified as the final key to morning report effectiveness. Specific behavior examples are provided. CONCLUSION: Consideration of content preparation, delivery, pedagogical approaches, and moderation of faculty participation are key components to Chief Resident-led morning reports. Results from this study could be used to enhance faculty development for Chief Residents.

Gender bias in resident evaluations: Natural language processing and competency evaluation.

BACKGROUND: Research shows that female trainees experience evaluation penalties for gender non-conforming behaviour during medical training. Studies of medical education evaluations and performance scores do reflect a gender bias, though studies are of varying methodology and results have not been consistent. OBJECTIVE: We sought to examine the differences in word use, competency themes and length within written evaluations of internal medicine residents at scale, considering the impact of both faculty and resident gender. We hypothesised that female internal medicine residents receive more negative feedback, and different thematic feedback than male residents. METHODS: This study utilised a corpus of 3864 individual responses to positive and negative questions over the course of six years (2012-2018) within Yale University School of Medicine's internal medicine residency. Researchers developed a sentiment model to assess the valence of evaluation responses. We then used natural language processing (NLP) to evaluate whether female versus male residents received more positive or negative feedback and if that feedback focussed on different Accreditation Council for Graduate Medical Education (ACGME) core competencies based on their gender. Evaluator-evaluatee gender dyad was analysed to see how it impacted quantity and quality of feedback. RESULTS: We found that female and male residents did not have substantively different numbers of positive or negative comments. While certain competencies were discussed more than others, gender did not seem to influence which competencies were discussed. Neither gender trainee received more written feedback, though female evaluators tended to write longer evaluations. CONCLUSIONS: We conclude that when examined at scale, quantitative gender differences are not as prevalent as has been seen in qualitative work. We suggest that further investigation of linguistic phenomena (such as context) is warranted to reconcile this finding with prior work.

A longitudinal, collaborative, practice-based learning and improvement model to improve post-discharge heart failure outcomes.

BACKGROUND: Practice-based learning and improvement is one of the Accreditation Council of Graduate Medical Education's core competencies fortrainees. Residencyprograms have grappled with how to accomplish this goal. AIM: We describe our institution's unique, longitudinal post-graduate year process and project. SETTING: West Haven, VA Medical Center. PARTICIPANTS: Yale University School of Medicine junior residents on ambulatory electives and faculty preceptor. PROGRAM DESCRIPTION: Longitudinal program aimed to decrease re-admissions for hospitalized patients with congestive heart failure. DISCUSSION: We feel that our longitudinal project is a novel innovation worthy of further study.

A Mentor, Advisor, and Coach (MAC) Program to Enhance the Resident and Mentor Experience.

Introduction: While residents must meet standardized educational milestones to graduate, individualized mentorship and guidance can help them achieve personal and career goals. A novel mentor, advisor, and coach (MAC) program was created for residents of the Yale University Traditional Internal Medicine Residency Program to help them attain these goals. Methods: Internal medicine faculty were recruited into the MAC program and matched with residents, with each faculty paired with one to three mentees. A structured roadmap was used to guide program content (including topics of mentoring, advising, and coaching), and meetings were individualized to cater to the needs of residents. During the 2017-2018 academic year, online surveys and focus groups were used to obtain feedback from participants. Results: Survey responses were obtained from 50 of the 116 residents (43%) and 21 of the 49 MAC faculty (43%). Thirteen residents and five MAC faculty participated in in-person focus groups. Most participants (92% of interns, 83% of residents, and 95% of MAC faculty) felt the program was beneficial and should continue. Individualized relationships and meeting content were key to the program's success. Areas for improvement included clarification of the program's purpose and each party's responsibilities in scheduling meetings. MAC faculty also requested faculty development tools to help them meet expectations of being a MAC. Discussion: The MAC program provided a successful avenue for mentorship and guidance for residents. Central themes to enhance participants' experience were individualization and flexibility, mutual agreement of the ground rules, and enhanced communication from program leadership.