Resident Remediation in Family Medicine Residency Programs: A CERA Survey of Program Directors.

BACKGROUND AND OBJECTIVES: Identifying underperforming residents and helping them become fully competent physicians is an important faculty responsibility. The process to identify and remediate these learners varies greatly between programs. The objective of this study was to evaluate the remediation landscape in family medicine residency programs by investigating resident remediation characteristics, tools to improve the process, and remediation challenges. METHODS: This study analyzed responses from the Council of Academic Family Medicine Educational Research Alliance (CERA) national survey of family medicine program directors in 2017. Survey questions included topics on faculty remediation training, remediation prevalence, tools for remediation, and barriers to remediation. RESULTS: Two hundred sixty-seven of 503 program directors completed our survey (53% response rate). Most residency programs (245/264, 93%) had at least one resident undergoing remediation in the last 3 years. A majority (242/265, 91%) of residents undergoing remediation were successful within 12 months. The three most important tools to improve remediation were an accessible remediation toolkit (50%), formal remediation recommendations from national family medicine organizations (20%), and on-site faculty development and training (19%). The top-two challenges to the remediation process were a lack of documented evaluations to trigger remediation and a lack of faculty knowledge and skills with effective remediation strategies. CONCLUSIONS: Residents needing remediation are common, but most were successfully remediated within 12 months. Program directors wanted access to a standardized toolkit to help guide the remediation process.

Point-of-Care Ultrasound in Family Medicine Residencies 5-Year Update: A CERA Study.

BACKGROUND AND OBJECTIVES: In 2014, family medicine residency programs began to integrate point-of-care ultrasound (POCUS) into training, although very few had an established POCUS curriculum. This study aimed to evaluate the resources, barriers, and scope of POCUS training in family medicine residencies 5 years after its inception. METHODS: Questions regarding current training and use of POCUS were included in the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors, and results compared to similar questions on the 2014 CERA survey. RESULTS: POCUS is becoming a core component of family medicine training programs, with 53% of program directors reporting establishing or an established core curriculum. Only 11% of program directors have no current plans to add POCUS training to their program, compared to 41% in 2014. Despite this increase in training, the reported clinical use of POCUS remains uncommon. Only 27% of programs use six of the eight surveyed POCUS modalities more than once per year. The top three barriers to including POCUS in residency training in 2019 have not changed since 2014, and are (1) a lack of trained faculty, (2) limited access to equipment, and (3) discomfort with interpreting images without radiologist review. CONCLUSIONS: Training in POCUS has increased in family medicine residencies over the last 5 years, although practical use of this technology in the clinical setting may be lagging behind. Further research should explore how POCUS can improve outcomes and reduce costs in the primary care setting to better inform training for this technology.

Integrated care coordination by an interprofessional team reduces emergency department visits and hospitalisations at an academic health centre.

People with chronic behavioural and physical health conditions have higher healthcare costs and mortality rates than patients with chronic physical conditions alone. As a result, there has been promotion of integrated care for this group. It is important to train primary care residents to practice in integrated models of care with interprofessional teams and to evaluate the effectiveness of integrated care models to promote high-quality care for this at-risk group. We implemented an integrated, interprofessional care management programme for adults with chronic mental and physical health needs as part of a curriculum for family medicine and family medicine psychiatry residents. We then evaluated the clinical effectiveness of this programme by describing participants' healthcare utilisation patterns pre- and post-enrolment. Patients enrolled in the programme were approximately 60-70% less likely to utilise the emergency room and 50% less likely to be admitted to the hospital after enrolment in the programme compared to before enrolment. The odds of individual attendance at outpatient primary care and mental health visits improved after enrolment. In the context of the implementation of integrated behavioural and physical healthcare in primary care, this interprofessional care management programme reduced emergency department utilisation and hospitalisations while improving utilisation of primary care and psychiatry outpatient care. Further studies should focus on replication of this model to further discern the model's cost-savings and health promotion effects.

Comparison of patient preferences for fecal immunochemical test or colonoscopy using the analytic hierarchy process.

BACKGROUND: In average-risk individuals aged 50 to 75 years, there is no difference in life-years gained when comparing colonoscopy every 10 years vs. annual fecal immunochemical testing (FIT) for colorectal cancer screening. Little is known about the preferences of patients when they have experienced both tests. METHODS: The study was conducted with 954 patients from the University of Iowa Hospital and Clinics during 2010 to 2011. Patients scheduled for a colonoscopy were asked to complete a FIT before the colonoscopy preparation. Following both tests, patients completed a questionnaire which was based on an analytic hierarchy process (AHP) decision-making model. RESULTS: In the AHP analysis, the test accuracy was given the highest priority (0.457), followed by complications (0.321), and test preparation (0.223). Patients preferred colonoscopy (0.599) compared with FIT (0.401) when considering accuracy; preferred FIT (0.589) compared with colonoscopy (0.411) when considering avoiding complications; and preferred FIT (0.650) compared with colonoscopy (0.350) when considering test preparation. The overall aggregated priorities were 0.517 for FIT, and 0.483 for colonoscopy, indicating patients slightly preferred FIT over colonoscopy. Patients' preferences were significantly different before and after provision of detailed information on test features (p < 0.0001). CONCLUSIONS: AHP analysis showed that patients slightly preferred FIT over colonoscopy. The information provided to patients strongly affected patient preference. Patients' test preferences should be considered when ordering a colorectal cancer screening test.

Management of skin and soft tissue infections in community practice before and after implementing a "best practice" approach: an Iowa Research Network (IRENE) intervention study.

CONTEXT: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a major pathogen among skin and soft tissue infections (SSTIs). Most CA-MRSA infections are managed initially on an outpatient basis. It is critical that primary care clinicians recognize and appropriately treat patients suspected of having such infections. OBJECTIVE: To identify and evaluate best methods and procedures for primary care clinicians to manage skin and soft tissue infections. DESIGN, SETTING, AND PATIENTS: Preintervention/postintervention study in eight Iowa Research Network offices conducted between October 2007 and August 2010. We reviewed medical records of 216 patients with SSTI before a set of interventions (preintervention) and 118 patients after the intervention (postintervention). INTERVENTIONS: Included a focus group meeting at each office, distribution of a modified Centers for Disease Control and Prevention (CDC) algorithm, "Outpatient Management of MRSA Skin and Soft Tissue Infections," education handouts, and an office policy for patients with skin infections. MAIN OUTCOME MEASURES: Proportion of subjects who were prescribed an antibiotic that would cover MRSA at the initial visit and proportion who were prescribed an antibiotic that would cover MRSA at any time. RESULTS: Three hundred sixty-eight forms (244 preintervention and 124 postintervention) were returned; 216 (89%) preintervention forms and 118 (95%) postintervention forms were usable. Multivariable logistic regression models found statistically significant and independent factors associated with MRSA coverage at the initial visit included being in the postintervention rather than the preintervention group, having an abscess component compared with cellulitis alone, having a culture sent, being prescribed two or fewer antibiotics, and not being hospitalized. CONCLUSIONS: The CDC algorithm was feasible for offices to use. Following a discussion of SSTI management in the outpatient setting, use of MRSA coverage increased both initially and overall. Thus, involving clinicians in a discussion about guidelines rather than simply providing guidelines or a didactic session may be a useful way to change physician practices.

Primary care clinicians' perspectives on management of skin and soft tissue infections: an Iowa Research Network study.

UNLABELLED: An estimated 95,000 people developed methicillin-resistant Staphylococcus aureus (MRSA) infections during 2005 of which 14% were community-associated and 85% were hospital or other health setting associated, and 19,000 Americans died from these infections that year. PURPOSE: To explore health care providers' perspectives on management of skin and soft tissue infections to gain a better understanding of the problems faced by busy providers in primary care settings. METHODS: Focus group meetings were held at 9 family physician offices in the Iowa Research Network. Seventy-eight clinicians including physicians, nurses, nurse practitioners, and house officers attended. Meeting audiotapes were transcribed and coded by 3 investigators, and a MRSA-management taxonomy was developed. FINDINGS: The main themes that emerged from the focus groups included epidemiology, diagnosis, treatment, management, prevention, special populations, and public relations. The incidence of MRSA infections was perceived to have increased over the past decade. However, diagnosis and treatment protocols for physicians in the outpatient setting have lagged behind, and no well-accepted diagnostic or treatment algorithms were used by physicians attending the focus groups. CONCLUSION: The clinicians in this study noted considerable confusion and inconsistency in the management of skin and soft tissue infections, particularly those due to MRSA.

Does structured audit and feedback improve the accuracy of residents' CPT E&M coding of clinic visits?

BACKGROUND AND OBJECTIVES: Family physicians frequently err when applying Current Procedural Terminology (CPT) evaluation and management (E&M) codes to their office visits, but there are few published prospective studies on educational interventions to improve coding. METHODS: Over a 6-year intervention period, 429 resident patient notes from return clinic visits were recoded by a faculty member with coding expertise. Feedback on coding accuracy and annual educational coding workshops were provided to the residents. Coding accuracy was calculated by subtracting residents' code from that of the faculty. Coding accuracy was analyzed cross-sectionally using all available data and longitudinally for 14 residents with data from all 3 years of the residency. RESULTS: Analysis of codings by 68 residents found that residents undercoded their clinic visits by 0.49 levels of service. Higher training year of the resident was associated with more accurate coding. Improvement over time was also found with the longitudinal analysis. However, comparison of 23 residents' coding from before the first feedback and didactic session to codings after starting feedback suggests that these improvements were not due to the intervention. CONCLUSIONS: Residents improved in coding accuracy over time, but our educational intervention may not have been responsible for the improvement.

Using systematically observed clinical encounters (SOCEs) to assess medical students' skills in clinical settings.

INTRODUCTION: The Objective Structured Clinical Examination (OSCE) is widely used to assess the clinical performance of medical students. However, concerns related to cost, availability, and validity, have led educators to investigate alternatives to the OSCE. Some alternatives involve assessing students while they provide care to patients - the mini-CEX (mini-Clinical Evaluation Exercise) and the Long Case are examples. We investigated the psychometrics of systematically observed clinical encounters (SOCEs), in which physicians are supplemented by lay trained observers, as a means of assessing the clinical performances of medical students. METHODS: During the pediatrics clerkship at the University of Iowa, trained lay observers assessed the communication skills of third-year medical students using a communication checklist while the students interviewed and examined pediatric patients. Students then verbally presented their findings to faculty, who assessed students' clinical skills using a standardized form. The reliability of the combined communication and clinical skills scores was calculated using generalizability theory. RESULTS: Fifty-one medical students completed 199 observed patient encounters. The mean combined clinical and communication skills score (out of a maximum 45 points) was 40.8 (standard deviation 3.3). The calculated reliability of the SOCE scores, using generalizability theory, from 10 observed patient encounters was 0.81. Students reported receiving helpful feedback from faculty after 97% of their observed clinical encounters. CONCLUSION: The SOCE can reliably assess the clinical performances of third-year medical students on their pediatrics clerkship. The SOCE is an attractive addition to the other methods utilizing real patient encounters for assessing the skills of learners.

Physician and pharmacist collaboration to improve blood pressure control.

BACKGROUND: Studies have demonstrated that blood pressure (BP) control can be improved when clinical pharmacists assist with patient management. The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control. METHODS: This was a prospective, cluster randomized, controlled clinical trial with clinics randomized to a control group (n = 3) or to an intervention group (n = 3). The study enrolled 402 patients (mean age, 58.3 years) with uncontrolled hypertension. Clinical pharmacists made drug therapy recommendations to physicians based on national guidelines. Research nurses performed BP measurements and 24-hour BP monitoring. RESULTS: The mean (SD) guideline adherence scores increased from 49.4 (19.3) at baseline to 53.4 (18.1) at 6 months (8.1% increase) in the control group and from 40.4 (22.6) at baseline to 62.8 (13.5) at 6 months (55.4% increase) in the intervention group (P = .09 for adjusted between-group comparison). The mean BP decreased 6.8/4.5 mm Hg in the control group and 20.7/9.7 mm Hg in the intervention group (P < .05 for between-group systolic BP comparison). The adjusted difference in systolic BP was -12.0 (95% confidence interval [CI], -24.0 to 0.0) mm Hg, while the adjusted difference in diastolic BP was -1.8 (95% CI, -11.9 to 8.3) mm Hg. The 24-hour BP levels showed similar effect sizes. Blood pressure was controlled in 29.9% of patients in the control group and in 63.9% of patients in the intervention group (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1; P < .001). CONCLUSIONS: A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group. Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00201019.

Trained lay observers can reliably assess medical students' communication skills.

CONTEXT: Our project investigated whether trained lay observers can reliably assess the communication skills of medical students by observing their patient encounters in an out-patient clinic. METHODS: During a paediatrics clerkship, trained lay observers (standardised observers [SOs]) assessed the communication skills of Year 3 medical students while the students interviewed patients. These observers accompanied students into examination rooms in an out-patient clinic and completed a 15-item communication skills checklist during the encounter. The reliability of the communication skills scores was calculated using generalisability analysis. Students rated the experience and the validity of the assessment. The communication skills scores recorded by the SOs in the clinic were correlated with communication skills scores on a paediatrics objective structured clinical examination (OSCE). RESULTS: Standardised observers accompanied a total of 51 medical students and watched 199 of their encounters with paediatric patients. The reliability of the communication skills scores from nine observed patient encounters was calculated to be 0.80. There was substantial correlation between the communication skills scores awarded by the clinic observers and students' communication skills scores on their OSCE cases (r = 0.53, P < 0.001). Following 83.8% of the encounters, students strongly agreed that the observer had not interfered with their interaction with the patient. After 95.8% of the encounters, students agreed or strongly agreed that the observers' scoring of their communication skills was valid. CONCLUSIONS: Standardised observers can reliably assess the communication skills of medical students during clinical encounters with patients and are well accepted by students.

Fertility awareness-based methods: another option for family planning.

Modern fertility awareness-based methods (FABMs) of family planning have been offered as alternative methods of family planning. Billings Ovulation Method, the Creighton Model, and the Symptothermal Method are the more widely used FABMs and can be more narrowly defined as natural family planning. The first 2 methods are based on the examination of cervical secretions to assess fertility. The Symptothermal Method combines characteristics of cervical secretions, basal body temperature, and historical cycle data to determine fertility. FABMs also include the more recently developed Standard Days Method and TwoDays Method. All are distinct from the more traditional rhythm and basal body temperature methods alone. Although these older methods are not highly effective, modern FABMs have typical-use unintended pregnancy rates of 1% to 3% in both industrialized and nonindustrialized nations. Studies suggest that in the United States physician knowledge of FABMs is frequently incomplete. We review the available evidence about the effectiveness for preventing unintended pregnancy, prognostic social demographics of users of the methods, and social outcomes related to FABMs, all of which suggest that family physicians can offer modern FABMs as effective means of family planning. We also provide suggestions about useful educational and instructional resources for family physicians and their patients.

Influence of patient characteristics on success of ambulatory blood pressure monitoring.

STUDY OBJECTIVE: To examine the influence of specific patient characteristics on the success of ambulatory blood pressure monitoring (ABPM). DESIGN: Retrospective analysis. SETTING: University-affiliated family care center. PATIENTS: Five hundred thirty patients (mean age 52.7 yrs, range 14-90 yrs) who were undergoing ABPM between January 1, 2001, and July 1, 2007. MEASUREMENT AND MAIN RESULTS: Specific patient characteristics were identified through an electronic medical record review and then examined for association with ABPM session success rate. These patient characteristics included age, sex, weight, height, body mass index (BMI), occupation, clinic blood pressure, travel distance to clinic, and presence of diabetes mellitus or renal disease. The percentage of valid readings obtained during an ABPM session was analyzed continuously (0-100%), whereas overall session success was analyzed dichotomously (0-79% or 80-100%). Univariate and multivariate regression analyses were performed to examine the influence of patient characteristics on the percentage of valid readings and the overall likelihood of achieving a successful session. In the 530 patients, the average percentage of valid readings was 90%, and a successful ABPM session (>or= 80% valid readings) was obtained in 84.7% (449 patients). A diagnosis of diabetes was found to negatively predict ABPM session success (continuous variable analysis, p=0.019; dichotomous variable analysis, odds ratio [OR] 0.45, 95% confidence interval [CI] 0.23-0.87, p=0.019), as did renal disease (continuous variable analysis, p=0.006; dichotomous variable analysis, OR 0.39, 95% CI 0.17-0.90, p=0.027) and increasing BMI (continuous variable analysis, p<0.001; dichotomous variable analysis, OR 0.78, 95% CI 0.65-0.93, p=0.005). Renal disease and BMI remained significant predictors in adjusted analyses. CONCLUSION: For most patients, ABPM was successful; however, elevated BMI and renal disease were associated with less complete ABPM session results. Adaptation and individualization of the ABPM process may be necessary to improve results in these patients.

How well does a shortened time interval characterize results of a full ambulatory blood pressure monitoring session?

Ambulatory blood pressure monitoring (ABPM) is useful in evaluating cardiovascular risk but requires significant time. The authors examined how closely shortened time intervals correlate with the systolic blood pressure (BP) determined from a full 24-hour ABPM session in 1004 ABPM recordings. After excluding the first hour, Pearson correlations performed for the mean systolic BP of the subsequent 3-, 5-, and 7-hour periods (4, 6, and 8 hours total) with the entire, and remainder of the session, demonstrated greatest improvement in correlation when the session is increased from 4 to 6 hours. Bland-Altman analysis of the 6-hour time period revealed a mean difference of 5.41 mm Hg compared with the full session mean. The authors conclude that 6-hour ABPM can approximate the overall mean BP obtained from full 24-hour ABPM. However, shortened sessions do not characterize the influence of circadian variation on the 24-hour mean BP and may overestimate the 24-hour BP levels.

A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control.

This was a prospective, cluster randomized controlled trial in patients with uncontrolled hypertension aged 21 to 85 years (mean, 61 years). Pharmacists made recommendations to physicians for patients in the intervention clinics (n=101) but not patients in the control clinics (n=78). The mean adjusted difference in systolic blood pressure (BP) between the control and intervention groups was 8.7 mm Hg (95% confidence interval [CI], 4.4-12.9), while the difference in diastolic BP was 5.4 mm Hg (CI, 2.8-8.0) at 9 months. The 24-hour BP levels showed similar effects, with a mean systolic BP level that was 8.8 mm Hg lower (CI, 5.0-12.6) and a mean diastolic BP level that was 4.6 mm Hg (CI, 2.4-6.8) lower in the intervention group. BP was controlled in 89.1% of patients in the intervention group and 52.9% in the control group (adjusted odds ratio, 8.9; CI, 3.8-20.7; P<.001). Physician/pharmacist collaboration achieved significantly better mean BP values and overall BP control rates, primarily by intensification of medication therapy and improving patient adherence.

The reliability of summative judgements based on objective structured clinical examination cases distributed across the clinical year.

CONTEXT: Objective structured clinical examinations (OSCEs) can be used for formative and summative evaluation. We sought to determine the generalisability of students' summary scores aggregated from formative OSCE cases distributed across 5 clerkships during Year 3 of medical school. METHODS: Five major clerkships held OSCEs with 2-4 cases each during their rotations. All cases used 15-minute student-standardised patient encounters and performance was assessed using clinical and communication skills checklists. As not all students completed every clerkship or OSCE case, the generalisability (G) study was an unbalanced student x (case : clerkship) design. After completion of the G study, a decision (D) study was undertaken and phi (phi) values for different cut-points were calculated. RESULTS: The data for this report were collected over 2 academic years involving 262 Year 3 students. The G study found that 9.7% of the score variance originated from the student, 3.1% from the student-clerkship interaction, and 87.2% from the student-case nested within clerkship effect. Using the variance components from the G study, the D study suggested that if students completed 3 OSCE cases in each of the 5 different clerkships, the reliability of the aggregated scores would be 0.63. The phi, calculated at a cut-point 1 standard deviation below the mean, would be approximately 0.85. CONCLUSIONS: Aggregating case scores from low stakes OSCEs within clerkships results in a score set that allows for very reliable decisions about which students are performing poorly. Medical schools can use OSCE case scores collected over a clinical year for summative evaluation.

The influence of irrelevant anchors on the judgments and choices of doctors and patients.

BACKGROUND: Little research has examined how anchor numbers affect choice, despite several decades of research showing that judgments typically and robustly assimilate toward irrelevant anchors. METHODS: In one experiment, HIV-positive patients (N = 99) judged the chances that sexual partners would become infected with HIV after sex using a defective condom and then indicated their choices of remedial action. In a second experiment, Iowa physicians (N =191) rated the chances that hypothetical patients had a pulmonary embolism and then formulated a treatment plan. RESULTS: Irrelevant anchor numbers dramatically affected judgments by HIV-infected patients of the chances of HIV infection after a condom broke during sex (43% v. 64% in the low- and high-anchor conditions, respectively) and judgments by doctors of the chances of pulmonary embolism (23% v. 53%, respectively). Despite large anchoring effects in judgement, treatment choices did not differ between low-and high-anchor conditions. Accountability did not reduce the anchoring bias in the doctors' judgments. DISCUSSION: The practical implications of anchoring for risk judgments are potentially large, but the bias may be less relevant to treatment choices. The findings suggest that the theoretical underpinnings of the anchoring bias may be more complex than previously thought.

Explicit and implicit evaluation of physician adherence to hypertension guidelines.

This study evaluated physician adherence to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) hypertension guidelines in 6 community-based clinics. Explicit review of retrospective medical record data for patients with uncontrolled hypertension measured guideline adherence using 22 criteria. Mean overall guideline adherence was 53.5% and did not improve significantly over time. Random-effects models demonstrated significant associations between guideline adherence and various demographic and medical predictors, including age, minority status, comorbid conditions, and number of medications. A subsequent implicit review evaluated the degree to which nonadherence was justifiable and identified factors that might have affected adherence. Nonadherence was rated as justifiable for only 6.6% of the failed explicit criteria. In general, adherence to the JNC 7 guidelines was modest even when barriers that might have affected adherence were taken into consideration.