Implementation of Case Conferences to Improve Interprofessional Collaboration in Resident Continuity Clinic.

OBJECTIVES: Residents must be trained in skills for interprofessional collaboration and team-based care in the outpatient setting, and successful models are needed to achieve this aim. A longitudinal curriculum was developed to enhance residents' knowledge of interprofessional team members' roles, residents' attitudes toward team-based care, and patient referrals to team members. METHODS: Postgraduate year 1 through postgraduate year 3 internal medicine residents with continuity clinic at a large hospital-based practice received the curriculum. Residents with continuity clinic at another site did not receive the curriculum and served as controls. Intervention residents attended five small-group conferences during the course of 1 year, each dedicated to a specific interprofessional discipline: pharmacy, psychology, diabetes/nurse education, social work, and case management. Conferences involved interactive, case-based discussions of patients who benefit from an interprofessional approach. Control and intervention residents were surveyed with pre- and posttests. The rates of patient referrals to interprofessional team members were assessed. RESULTS: Seventy-one residents received the curriculum. Intervention residents' knowledge of team members' names and roles, indications for patient referral, and communication methods improved after curriculum implementation. Attitudes toward team-based care did not change but were positive at baseline. Following curriculum implementation, new patient referrals increased for the pharmacist (0.1-1/100 patient visits, P = 0.015) and psychologist (1.1-2.2/100 patient visits, P = 0.032). CONCLUSIONS: Case-based interprofessional conferences improved residents' knowledge regarding interprofessional care and increased referrals to team members. This curriculum addresses barriers to team-based care experienced by residents in continuity clinic and is adaptable to other clinic settings.

Training Residents to Work in a Patient-Centered Medical Home: What Are the Outcomes?

Background The patient-centered medical home (PCMH) provides a setting to enhance resident training in systems-based practice. Few studies have addressed the impact of PCMHs on resident knowledge and confidence. Objective The goal of this study was to evaluate resident knowledge, confidence, behavior, and patient outcomes in a PCMH. Methods Our curriculum emphasized patient panel report card interpretation, a telephone medicine curriculum, and interdisciplinary team-based care of chronic medical conditions. We measured resident satisfaction, knowledge, and confidence. Patient outcomes included hemoglobin A1c (HbA1c) and blood pressures. Prescores and postscores were compared using paired t tests for continuous measures and McNemar's test for binary measures. Results A total of 154 residents were eligible for the curriculum. All residents participated in the curriculum, though not all residents completed the evaluation. Completion rates for paired pre-post knowledge and confidence surveys were 38% and 37%, respectively. Nearly 80% (69 of 87) of residents indicated that the curriculum was above average or outstanding. Our evaluation revealed very small immediate improvements in knowledge and confidence. No significant improvement in patients' HbA1cs or blood pressures occurred after the curriculum. Conclusions Explicit training to work in a PCMH was feasible and resulted in high levels of resident satisfaction and immediate small improvements in knowledge and confidence.

Primary care of the renal transplant patient.

There has been a remarkable rise in the number of kidney transplant recipients (KTR) in the US over the last decade. Increasing use of potent immunosuppressants, which are also potentially diabetogenic and atherogenic, can result in worsening of pre-existing medical conditions as well as development of post-transplant disease. This, coupled with improving long-term survival, is putting tremendous pressure on transplant centers that were not designed to deliver primary care to KTR. Thus, increasing numbers of KTR will present to their primary care physicians (PCP) post-transplant for routine medical care. Similar to native chronic kidney disease patients, KTRs are vulnerable to cardiovascular disease as well as a host of other problems including bone disease, infections and malignancies. Deaths related to complications of cardiovascular disease and malignancies account for 60-65% of long-term mortality among KTRs. Guidelines from the National Kidney Foundation and the European Best Practice Guidelines Expert Group on the management of hypertension, dyslipidemia, smoking, diabetes and bone disease should be incorporated into the long-term care plan of the KTR to improve outcomes. A number of transplant centers do not supply PCPs with protocols and guidelines, making the task of the PCP more difficult. Despite this, PCPs are expected to continue to provide general preventive medicine, vaccinations and management of chronic medical problems. In this narrative review, we examine the common medical problems seen in KTR from the PCP's perspective. Medical management issues related to immunosuppressive medications are also briefly discussed.

Primary care of the transplant patient.

A total of 153,245 patients are living with a solid organ transplant in the US. In addition, patients are experiencing high 5-year survival rates after transplantation. Thus, primary care physicians will be caring for transplanted patients. The aim of this review is to update primary care physicians on chronic diseases, screening for malignancy, immunizations, and contraception in the transplant patient. Several studies on the treatment of hypertension and hyperlipidemia demonstrate that most agents used to treat the general population also can be used to treat transplant recipients. Little information exists on the medical management of diabetes in the transplant population, but experts in the area believe that the treatment of diabetes should be similar. Transplant recipients are at increased risk for all malignancies. Aggressive screening should be employed for all cancers with a proven screening benefit. Killed immunizations are safe for the transplant population, but live virus vaccines should be avoided. Women of childbearing age should be counseled about the impact of immunosuppressants on the efficacy and side effects of contraception.

Summative evaluation on the hospital wards. What do faculty say to learners?

No previous studies have described how faculty give summative evaluations to learners on the medical wards. The aim of this study was to describe summative evaluations on the medical wards. Participants were students, house staff and faculty at the University of Pittsburgh. Ward rotation evaluative sessions were tape recorded. Feedback was characterized as to whether it was: (a) general or specific; (b) positive versus corrective; (c) elaborative or simple; and (d) for corrective feedback, if an action plan was discussed. 68 evaluation sessions were recorded. 86% of sessions included general, positive statements. On average, seven specific statements were made per feedback session: five were positive and two were corrective. 52% of comments were elaborated. In 41% of cases, the learner was given an action plan for improvement. During a summative evaluation faculty do not elaborate on the learner's behavior. This is particularly true when giving corrective feedback.