Chicago's Citywide COVID-19 Vaccine Equity Program: Protect Chicago Plus.

Vaccination is one of the most effective strategies to control the spread of COVID-19 and reduce morbidity and mortality; however, rapid and equitable vaccine distribution is required to achieve such outcomes. We conducted a basic interrupted time-series analysis to examine the short-term impacts of a citywide vaccine equity plan, the Protect Chicago Plus (PCP) plan. We compared vaccine coverage in zip codes in Chicago with high COVID-19 vulnerability, as identified from the Chicago COVID-19 Community Vulnerability Index, with coverage in all other zip codes in Chicago. From our analysis, we observed that implementation of PCP coincided with reduced vaccination disparities between Chicago communities with low and high vulnerability indexes over time. In our analysis of vaccination coverage before program implementation, vaccination coverage climbed nearly twice as fast among non-PCP zip codes (0.19% per day) than among PCP zip codes (0.10% per day) or by 0.09 percentage points (P < .001). In model analysis after program implementation, zip codes prioritized for the program had 0.42% additional coverage per day as compared with 0.27% per day for non-PCP zip codes. Our findings suggest that such programs may improve vaccine equity, but additional research is needed to better understand the longer-term effects of citywide vaccination strategies on vaccine uptake.

Interprofessional transformation of clinical education: The first six years of the Veterans Affairs Centers of Excellence in Primary Care Education.

This paper describes the Centers of Excellence in Primary Care Education (CoEPCE), a seven-site collaborative project funded by the Office of Academic Affiliations (OAA) within the Veterans Health Administration of the United States Department of Veterans Affairs (VA). The CoEPCE was established to fulfill OAA's vision of large-scale transformation of the clinical learning environment within VA primary care settings. This was accomplished by funding new Centers within VA facilities to develop models of interprofessional education (IPE) to teach health professions trainees to deliver high quality interprofessional team-based primary care to Veterans. Using reports and data collected and maintained by the National Coordinating Center over the first six years of the project, we describe program inputs, the multicomponent intervention, activities undertaken to develop the intervention, and short-term outcomes. The findings have implications for lessons learned that can be considered by others seeking large-scale transformation of education within the clinical workplace and the development of interprofessional clinical learning environments. Within the VA, the CoEPCE has laid the foundation for IPE and collaborative practice, but much work remains to disseminate this work throughout the national VA system.

Interprofessional grant writing seminar for early career faculty in a small, isolated teaching center.

Small, isolated teaching centers have difficulty mentoring interprofessional junior faculty in research methods and grant writing. Peer mentoring programs for grant writing at larger institutions have been successful. In this short report, we describe our program that leveraged mentor experience using four framing seminars followed by project refinement in three-person peer groups and monthly mentored works in progress meetings. In its first year, ten faculty from medicine, psychology, and pharmacy completed the program and successfully obtained six funded grants. Five of the projects transitioned from single profession applications to interprofessional applications as participants connected and profession-specific expertise was identified. Refinements for future cohorts are discussed.

Impact of a complex chronic care patient case conference on quality and utilization.

There is need for effective venues to allow teams to coordinate care for high-risk or high-need patients. In addition, health systems need to assess the impact of such approaches on outcomes related to chronic health conditions and patient utilization. We evaluate the clinical impact of a novel case conference involving colocated trainees and supervisors in an interprofessional academic primary care clinic. The study utilized a prospective cohort with control group. Intervention patients (N = 104) were matched with controls (N = 104) from the same provider's panel using propensity scores based on age, gender, risk predictors, and prior utilization patterns. Clinical outcomes and subsequent utilization patterns were compared prior to and up to 6 months following the conference. In terms of utilization, intervention patients demonstrated increased visits with primary care team members (p = .0002) compared with controls, without a corresponding increase in the number of primary care providers' visits. There was a trend towards decreased urgent care and emergency visits (p = .07) and a significant decrease in the rate of hospitalizations (p = .04). Patients with poorly-controlled hypertension saw significant decreases in mean systolic blood pressure from 167 to 146 mm Hg. However, there were no differences between the intervention and control groups. Intervention patients with diabetes demonstrated a nonsignificant trend towards decreased hemoglobin A1c from 9.8 to 9.4, when compared with controls. Interprofessional case conferences have potential to improve care coordination and may be associated with improved disease management, decreased unplanned care, and overall reduced hospitalizations.

The Foundations of interprofessional curriculum. Finding the right epistemology and learning theory for the task.

This article was migrated. The article was marked as recommended. Introduction: Health professional education programs are currently focusing on interprofessional training. This can highlight differences between our professions in our learning theories and training assumptions. A standardized approach to picking a deliberate perspective from which to design specific interprofessional curricula may be useful. Discourses: This paper presents one such approach. It is based on a 3 X 3 matrix developed by interprofessional faculty over seven years of team-based clinical training. To use this matrix, a deliberate epistemology (e.g., reductionist, constructivist, or complexity) and a learning theory (competency-based education, clinical reasoning, and situated learning) are chosen based on the goals of training, the context, and the developmental stage of the learners. Application: Each element in the matrix then provides a focused set of considerations for designing and assessing interprofessional curriculum. In addition, this matrix provides a framework for incorporating other epistemologies and learning theories. Conclusions: As professionals, we have been enculturated to see health education from a single perspective. A wider, structured approach to adopting learning assumptions and theories may better match the interprofessional training tasks we are being asked to design.

Interprofessional Care Conferences for High-Risk Primary Care Patients.

PROBLEM: As health care systems convert to team-based care, the need to improve interprofessional education is tremendous. In addition to formal instruction, trainees need authentic team-based workplace learning experiences. APPROACH: The authors designed the PACT-ICU (Patient-Aligned Care Team Interprofessional Care Update) conference to provide team-based care to high-risk patients while teaching trainees principles of interprofessionalism and modeling relevant behaviors. Trainees, supervisors, and affiliated support staff from the fields of internal medicine, nurse practitioner, pharmacy, psychology, and nursing all participate in this conference. During the conference, each participant focuses on the narrative of the patient's illness from his/her own professional perspective. A multifaceted care plan with specific action items is the product of the conference. To evaluate this workplace learning opportunity, the authors recorded patient characteristics, plus trainees' participation and satisfaction. OUTCOMES: Over the first 16 months (2013-2014) of the PACT-ICU, 33 trainees presented 79 patients. Each trainee presented two or three times each academic year. Patients were 90% male; their mean age was 64.5 years (SD 9.3, range 28-92), and their mean calculated 90-day risk of death or hospitalization was 22% (SD 14%, range 1%-45%).Overall, all surveyed trainees (n = 32; 97% response rate) expressed satisfaction, reporting that the conference was "helpful" or "very helpful" in developing treatment plans. NEXT STEPS: Further assessment of change in trainee behavior related to interprofessional team care, patient-level outcomes (e.g., quality of care and utilization), and factors facilitating dissemination of the model to other academic clinic settings is necessary.

Professional equipoise: Getting beyond dominant discourses in an interprofessional team.

In 2011, the US Department of Veterans Affairs established five Centers of Excellence to study training in the patient-centered medical home clinical microsystem. Early on, our center began a discourse analysis in order to better understand each profession's assumptions about roles, responsibilities, and the basis for "truth" in clinical care. We discovered that these different discourses were pervasive and led to unhelpful stereotypes of each other. This article describes the evidence we identified that led us to hypothesize these conflicting discourses and stereotypes. Specifically, we report on our attempts to identify the traditional discourses of four post-graduate professions--medicine, nurse practitioner, psychology, and pharmacy. We also share lessons from our efforts to defuse participants from their identified discursive assumptions, and develop appreciation and value for the discursive contributions of other professions--a process we call professional equipoise. We conclude that we can change these discourses and the professional identity formation of novices if we provide sustained, integrated interprofessional education curriculum. This implies that we need: embedded, longitudinal training; faculty role modeling of inquisitiveness, respectful relationships, and risk taking; and safe and honest discussion about our differences.

Diagnostic Reasoning across the Medical Education Continuum.

We aimed to study linguistic and non-linguistic elements of diagnostic reasoning across the continuum of medical education. We performed semi-structured interviews of premedical students, first year medical students, third year medical students, second year internal medicine residents, and experienced faculty (ten each) as they diagnosed three common causes of dyspnea. A second observer recorded emotional tone. All interviews were digitally recorded and blinded transcripts were created. Propositional analysis and concept mapping were performed. Grounded theory was used to identify salient categories and transcripts were scored with these categories. Transcripts were then unblinded. Systematic differences in propositional structure, number of concept connections, distribution of grounded theory categories, episodic and semantic memories, and emotional tone were identified. Summary concept maps were created and grounded theory concepts were explored for each learning level. We identified three major findings: (1) The "apprentice effect" in novices (high stress and low narrative competence); (2) logistic concept growth in intermediates; and (3) a cognitive state transition (between analytical and intuitive approaches) in experts. These findings warrant further study and comparison.

A multisite, multistakeholder validation of the Accreditation Council for Graduate Medical Education competencies.

PURPOSE: The Accreditation Council for Graduate Medical Education's (ACGME's) six-competency framework has not been validated across multiple stakeholders and sites. The objective of this study was to perform a multisite validation with five stakeholder groups. METHOD: This was a cross-sectional, observational study carried out from October to December, 2011, in the internal medicine residency continuity clinics of eight internal medicine residency programs in the Pacific Northwest, including a VA, two academic medical centers, a military medical center, and four private hospitals. The authors performed a cultural consensus analysis (CCA) and a convergent-discriminant analysis using previously developed statements based on internal medicine milestones related to the six competencies. Ten participants were included from each of five stakeholder groups: patients, nurses, residents, faculty members, and administrators from each training site (total: 400 participants). RESULTS: Moderate to high agreement and coherence for all groups were observed (CCA eigenvalue ratios ranging from 2.16 to 3.20); however, high differences in ranking order were seen between groups in four of the CCA statements, which may suggest between-group tension in these areas. Analyses revealed excellent construct validity (Zcontrast score of 5.323, P < .0001) for the six-competency framework. Average Spearman correlation between same-node statements was 0.012, and between different-node statements it was -0.096. CONCLUSIONS: The ACGME's six-competency framework has reasonable face and construct validity across multiple stakeholders and sites. Stakeholders appear to share a single mental model of competence in this learning environment. Data patterns suggest possible improvements to the competency-milestone framework.

The EFECT framework for interprofessional education in the patient centered medical home.

The very nature of the Patient-Centered Medical Home (PCMH) necessitates new instructional models that prepare learners for the roles they will have to assume in these transformed primary care practices. In this manuscript we describe a new instructional framework that seeks to blend the goals of patient-centered care and inter-professional education, and can be implemented in existing training environments while practice transformation continues to proceed. We propose a 5-step process, the EFECT framework, which is simultaneously a sequence of tasks for effective patient care and a guide for the learners and faculty in teaching and evaluating that care delivery. These steps include: (1) Eliciting a patient-centered narrative, (2) Facilitating an inter-professional team discussion, (3) Evaluating clinical evidence, (4) Creating a shared care plan, and (5) Tracking outcomes. We then report preliminary descriptive outcomes from the first EFECT pilot. Our proposed framework supports learners' abilities to construct a patient-centered narrative from multiple professional perspectives as the basis for developing an evidence-based, integrated care plan between the patient and the inter-professional care team and deliberately following up on outcomes. We present this framework to stimulate a process for creating new curricula and evaluative tools to measure and promote learner functioning in medical home environments.

Developing a Cultural Consensus Analysis Based on the Internal Medicine Milestones (M-CCA).

A national task force identified domains and developmental milestones from the national competencies for resident training. Cultural Consensus Analysis (CCA) is a standard anthropological technique that can identify value conflicts. We created a CCA based on the internal medicine milestones (M-CCA) in 3 steps: converted the 38 domains into active statements; reduced the total number to 12 by summarizing and combining; and simplified the wording. This M-CCA needs further validation, after which it may be useful for assessing the 6-competency model.

Resident perceptions of the educational value of night float rotations.

BACKGROUND: Night float rotations are being increasingly used in the era of resident physician work-hour regulations, but their impact on resident education is not clear. PURPOSE: Our objective was to clarify resident perceptions of the educational aspects of night float rotations. METHODS: An anonymous survey of internal medicine residents at a university-based residency program was completed. RESULTS: Responses were received from 116 of 163 surveyed residents (71%). Residents attended less residents' report (0.10 +/- .43 vs. 2.70 + 0.93 sessions/week, p< .001) and fewer grand rounds sessions (0.14 +/- 0.25 vs. 0.43 +/- 0.28 sessions/week, p< .001) and spent less time reading, (2.63 +/- 2.0 vs. 3.33 +/- 1.6 hr/week, p< .001) interacting with attending physicians (0.57 +/- 1.1 vs. 2.97 +/- 1.5 hr/week, p< .001) and sleeping at home (6.3 +/- 1.2 vs. 7.10 +/- 0.9 hr/day, p< .001) on night float rotations than on non-night float rotations. Residents had strongly negative opinions about the educational value of night float, sleep cycle adjustment issues, and impact on their personal lives, which correlated with resident evaluations from the regular program evaluation process. In free responses, residents commented that they liked the autonomy and opportunity to improve triage skills on these rotations and confirmed their negative opinions about the sleep-wake cycle and interference with personal lives. CONCLUSIONS: Internal medicine residents at a university-based program have negative opinions regarding the educational value of night float rotations. Further work is necessary to determine whether problems exist across programs and specialties.

Toward an ecological perspective of resident teaching clinic.

Teaching clinic managers struggle to convert performance data into meaningful behavioral change in their trainees, and quality improvement measures in medicine have had modest results. This may be due to several factors including clinical performance being based more on team function than individual action, models of best practice that are over-simplified for real patients with multiple chronic diseases, and local features that influence behavior but are not aligned with core values. Many are looking for a new conceptual structure to guide them. In this paper we briefly review several theories of action from the social and complexity sciences, and synthesize these into a coherent 'ecological perspective'. This perspective focuses on stabilizing features and narrative, which select for behaviors in clinic much like organisms are selected for in an ecosystem. We have found this perspective to be a useful guide for design, measurement, and joint learning in the teaching clinic.

A developmental approach to evaluating competence in clinical reasoning.

In the past two decades there has been tremendous worldwide interest in assessing the clinical competence of learners in medical education. This interest marks a philosophical shift toward greater objectivity, accountability, and predictive power in the evaluation of trainees. One of the core competencies in medical education is clinical reasoning. Because veterinary and human medical training share several similarities and differences, a review of the current state of clinical reasoning competency assessment in medical education may be useful for veterinary educators. This article covers the core competency of clinical reasoning (not other important competencies, such as physical examination or communication) and reviews research from medical education on the development of clinical reasoning and its implications for the transition from novice to expert. Four common stage-related learner difficulties are described: reduced knowledge, dispersed knowledge, tunnel vision, and the outsider. Specific approaches to measuring competence in clinical reasoning for each developmental level are recommended. Finally, two specific examples of evaluation based on a developmental approach to clinical expertise, the RIME (reporter, interpreter, manager, expert) system and the Script Concordance Test (SCT) methods, are discussed.

Cost effectiveness of regulation-compliant filtration to control sediment and metal pollution in urban runoff.

The implementation of Total Maximum Daily Load (TMDL) to control urban runoff presents major structural and managerial challenges for cities. We developed a decision support system (DSS) for TMDL compliance at the city level to solve for a phased, least-cost strategy toward meeting four TMDLs using stormwater filtration. Based on a case-study city, we modeled wet weather flows and associated discharge of Total Suspended Sediment (TSS), cadmium, copper, and zinc to receiving waters by coupling U.S. EPA's Storm Water Management Model (SWMM v. 5.0) with the geographic dataset of the urban drainage network. We linked a mixed integer linear programming algorithm to the watershed model for deriving cost-effective selection and placement of curb inlet filters to meet mass- and concentration-based TMDL requirements. The least cost solution for meeting the city's TMDL waste load allocations for TSS (73.9% reduction), Cd (50.6% reduction), Cu (30.0% reduction), and Zn (55.7% reduction) would require 1071 filter inserts at a cost of $1.7 million. In contrast, random placement of 1071 filters or uniform placement of 1266 filters is effective only for TSS and would cost $4.0 million and $4.8 million, respectively. Our results demonstrate the increases in cost-effectiveness of using an optimization-based DSS for urban watershed management.