International medical graduates' experiences with caring for cross-cultural patient populations: Qualitative study in Alberta.

OBJECTIVE: To explore experiences of international medical graduate (IMG) FPs in providing cross-cultural patient care and to identify rewards and challenges they experienced when caring for patients of cultural backgrounds different from their own. DESIGN: Descriptive qualitative study. SETTING: Family medicine primary care practices in Alberta. PARTICIPANTS: Eighteen IMG FPs practising in the metropolitan areas of Edmonton or Calgary in Alberta as of May 2013. METHODS: Individual face-to-face or telephone interviews were conducted using a semistructured interview guide. Seventeen interviews occurred between July and August 2013 and 1 took place in August 2014. All interviews were audiorecorded and transcribed verbatim. Transcribed data were subject to thematic analysis. MAIN FINDINGS: International medical graduates identified several rewarding aspects of caring for patients with cultural backgrounds different from their own, including learning about different cultures, perceiving that appointments are more succinct, and advocating for patients whom they perceive to be at a disadvantage. Family physicians also identified several challenges associated with caring for patients of different cultural backgrounds, including encountering language barriers, perceiving that visits take longer, and experiencing patients' lack of acceptance of FPs with cultural backgrounds different from their own. CONCLUSION: Cultural differences between FPs and patients can enhance or undermine doctor-patient relationships. The results of this study speak to the need for cultural competency training for FPs practising in culturally diverse settings.

What about Happiness? A Critical Narrative Review with Implications for Medical Education.

Introduction: Despite abundant scholarship and improvement initiatives, the problem of physician wellbeing persists. One reason might be conceptual: the idea of 'happiness' is rare in this work. To explore how it might influence the conversation about physician wellbeing in medical education, we conducted a critical narrative review asking: 'How does happiness feature in the medical education literature on physician wellbeing at work?' and 'How is happiness conceptualized outside medicine?' Methods: Following current methodological standards for critical narrative review as well as the Scale for the Assessment of Narrative Review Articles, we conducted a structured search in health research, humanities and social sciences, a grey literature search, and consultation with experts. After screening and selection, content analysis was performed. Results: Of 401 identified records, 23 were included. Concepts of happiness from the fields of psychology (flow, synthetic happiness, mindfulness, flourishing), organizational behaviour (job satisfaction, happy-productive worker thesis, engagement), economics (happiness industry, status treadmill), and sociology (contentment, tyranny of positivity, coercive happiness) were identified. The medical education records exclusively drew on psychological concepts of happiness. Discussion and Conclusion: This critical narrative review introduces a variety of conceptualizations of happiness from diverse disciplinary origins. Only four medical education papers were identified, all drawing from positive psychology which orients us to treat happiness as individual, objective, and necessarily good. This may constrain both our understanding of the problem of physician wellbeing and our imagined solutions. Organizational, economical and sociological conceptualizations of happiness can usefully expand the conversation about physician wellbeing at work.

An Approach to Leadership Development and Patient Safety and Quality Improvement Education in the Context of Professional Identity Formation in Pre-Clinical Medical Students.

Objectives: Leadership and patient safety and quality improvement (PSQI) are recognized as essential parts of a physician's role and identity, which are important for residency training. Providing adequate opportunities for undergraduate medical students to learn skills related to these areas, and their importance, is challenging. Methods: The Western University Professional Identity Course (WUPIC) was introduced to develop leadership and PSQI skills in second-year medical students while also aiming to instill these topics into their identities. The experiential learning portion was a series of student-led and physician-mentored PSQI projects in clinical settings that synthesized leadership and PSQI principles. Course evaluation was done through pre/post-student surveys and physician mentor semi-structured interviews. Results: A total of 108 of 188 medical students (57.4%), and 11 mentors (20.7%), participated in the course evaluation. Student surveys and mentor interviews illustrated improved student ability to work in teams, self-lead, and engage in systems-level thinking through the course. Students improved their PSQI knowledge and comfort levels while also appreciating its importance. Conclusion: The findings from our study suggest that undergraduate medical students can be provided with an enriching leadership and PSQI experience through the implementation of faculty-mentored but student-led groups at the core of the curricular intervention. As students enter their clinical years, their first-hand PSQI experience will serve them well in increasing their capacity and confidence to take on leadership roles.

Exploring medical students' perspectives of physician leadership.

BACKGROUND: Leadership has been recognized as an important competency in medicine. Nevertheless, leadership curricula for Canadian medical students lacks standardization and may not be informed by medical students' perspectives of physician leadership. The purpose of this study was to elicit these perspectives on physician leadership. METHODS: The present study utilized semi-structured interviews to ascertain the views of medical student participants, including students in their first, second and third years of medical school, on physician leadership. Interview questions were based on 'the 3-C model' of physician leadership, which includes three aspects of leadership, namely character, competence and commitment. The interviews were audio-recorded, transcribed and then coded using thematic analysis. RESULTS: The medical students of this study provided rich examples of resident and staff physicians demonstrating effective and ineffective leadership. The participants identified the importance of character to effective physician leadership, but some participants also described a feeling of disconnect with the relevance of character at their stage of training. When discussing physician competence, medical students described the importance of both medical expertise and transferable skills. Lastly, the leadership aspect of commitment was identified as being relevant, but medical students cautioned against the potential for physician burnout. The medical student participants' suggestions for improved leadership development included increased experiences with examples of physician leadership, opportunities to engage in leadership and participation in reflection exercises. CONCLUSIONS: Overall, the study participants demonstrated an appreciation for three aspects of leadership; character, competence and commitment. Furthermore, they also provided recommendations for the future design of medical leadership curricula.

"Influential" Intraoperative Educators and Variability of Teaching Styles.

OBJECTIVES: Academic surgeons manage their role as intraoperative educators in a variety of ways. Such variability is neither idiosyncratic nor is there a single best approach. This study sought to explore the practices of surgeons deemed influential by their residents, allowing insight into a variety of potentially effective practices. PARTICIPANTS: Constructivist grounded theory guided data collection and analysis. Data sources included surveys from senior surgical residents (PGY3-6) and recent graduates from an academic hospital in Canada (36% response rate), intraoperative observations of teaching interactions, and semi-structured interviews with observed surgeons. Rigour was supported by data triangulation, constant comparison, and collection to theoretical sufficiency. DESIGN: We developed a framework grouping effective teaching into three overlapping approaches: exacting, empowering, and fostering. The approaches differ based on the level of independence granted and the degree of expectation placed on individual residents. Each demonstrates different strategies for balancing the multiple supervisory roles and patient care obligations faced by academic surgeons. We also identified strategies that could be used across approaches to enhance learning. CONCLUSIONS: For surgical educators seeking to improve upon the quality of the intraoperative supervision they provide, frameworks such as this may serve as models of effective supervision. Enhancing surgeons' knowledge of proven strategies, combined with reflecting on how they teach and how they balance responsibilities to patients and trainees, may allow them to broaden their educational practice.

Documentation as composing: how medical students and residents use writing to think and learn.

Some educators have described clinical documentation as "scut". Research in medicine has focused on documentation's communicative value and not its function in learning. With time being an important commodity and electronic health records changing how we document, understanding the learning value of documentation is essential. The purpose of this study was to explore how trainee composing practices shape learning. Qualitative methods employing Rhetorical Genre Theory were used to explore clinical documentation practices among medical trainees. Data collection and analysis occurred in iterative cycles. Data included field notes and field interviews from 110 h of observing junior trainees and senior internal medicine residents participating in patient admission and follow-up visits. Analysis was focused on Paré and Smart's framework for studying documentation as composing. From a composing lens, documentation plays a vital role in learning in clinical settings. Junior trainees were observed to be reliant on using writing to support their thinking around patient care. Before patient encounters, writing helped trainees focus on what was already known and develop a preliminary understanding of the patient's problem(s). After encounters, writing helped trainees synthesize the data and develop an assessment and plan. Before and after the encounter, through writing, trainees also identified knowledge and data collection gaps. Our findings highlight clinical documentation as more than a communication task. Rather, the writing process itself appeared to play a pivotal role in supporting thinking. While some have proposed strategies for reducing trainee involvement, we argue that writing can be time well spent.

Perspectives on physician leadership: The role of character-based leadership in medicine.

INTRODUCTION: Physician leadership is multifaceted, but leadership training in medicine often is not. Leadership education and training for physicians are rarely grounded in conceptual leadership frameworks and suffer from a primary focus on cognitive leadership domains. Character-based leadership is a conceptual leadership framework that moves beyond cognitive competencies and articulates dimensions of character that promote effective leadership. The purpose of this study was to explore the relevance of character-based leadership in the medical context. METHODS: This qualitative descriptive study used semi-structured interviews to explore health care professionals' perceptions of character in relation to effective leadership in medicine. All interviews were audiorecorded and transcribed. Consistent with descriptive qualitative inquiry, a qualitative latent content analysis was used. Simultaneous data collection and analysis incorporating character-based leadership as a theoretical framework was used to help organise the analysis of the data. The researchers met regularly to clarify coding structures and categorise codes until sufficiency was reached. RESULTS: Twenty-six individuals (12 doctors, 5 nurses, 2 social workers, 2 directors and a pharmacist, dietician, coordinator, administrator and unit clerk) participated. Character-based leadership resonated with participants; they deemed character essential for effective physician leadership. Participants reflected on different character dimensions they attributed to an effective physician leader, in particular, collaboration, humility and humanity. They shared examples of working in interdisciplinary health care teams to illustrate these in practice. Moreover, participants believed that effective physician leaders need not be in a positional leadership role and asserted that physicians who demonstrate character stand out as leaders regardless of their career stage. DISCUSSION: Our findings suggest a role for a character-based leadership framework in medical education. Participants recognised the execution of character in everyday practice, associated character with effective leadership and understood leadership in dispositional rather than positional terms. These findings provide important insights for expanding and enhancing existing leadership training interventions.

From distress to detachment: exploring how providing care for stigmatized patients influences the moral development of medical trainees.

In acute hospital settings, medical trainees are often confronted with moral challenges and negative emotions when caring for complex and structurally vulnerable patients. These challenges may influence the long term moral development of medical trainees and have significant implications for future clinical practice. Despite the importance of moral development to medical education, the topic is still relatively under-explored. To gain a deeper understanding of moral development in trainees, we conducted a qualitative exploration of how caring for a stigmatized population influences their moral development. Data were collected from 48 medical trainees, including observational field notes, supplemental interviews, and medical documentation from inpatient units of two urban teaching hospitals in a Canadian context. Utilizing a practice-based approach which draws on constructivist grounded theory, we conducted constant comparative coding and analysis. We found that caring for stigmatized populations appeared to trigger frustration in medical trainees, which often perpetuated feelings of futility as well as avoidance behaviours. Additionally, hospital policies, the physical learning environment, variability in supervisory practices, and perceptions of judgment and mistrust all negatively influenced moral development and contributed to apathy and moral detachment which has implications for the future. Recognizing the dynamic and uncertain nature of care for stigmatized patients, and addressing the influence of structural and material factors provide an opportunity to support moral experiences within clinical training, and to improve inequities.

Interprofessional care of patients with type 2 diabetes mellitus in primary care: family physicians' perspectives.

BACKGROUND: There is a lack of understanding of the team processes and factors that influence teamwork and medication management practices in the care of patients with type 2 diabetes mellitus (T2DM). The purpose of the study was to explore physicians' perspectives of barriers and facilitators to interprofessional care of patients with T2DM within team-based family practice settings. METHODS: This was a qualitative, descriptive study. Participants included physicians affiliated with a primary care network providing care to patients with T2DM in an interprofessional team-based primary care setting in Edmonton, Alberta, Canada. Participants' contact information was obtained from the publicly available College of Physicians and Surgeons of Alberta and respective primary care network websites. Interview questions addressed physicians' perspectives on factors or processes that facilitated and hindered the care and medication management of adult patients with T2DM in primary care team-based clinical practice. Interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis and a constant comparative approach. RESULTS: A total of 15 family physicians participated in individual interviews. Family physicians identified facilitators of interprofessional team-based care and medication management of patients with T2DM in three theme areas-access to team members and programs, knowledgeable and skilled health professionals, and provision of patient education by other health professionals. Two themes emerged as barriers to interprofessional care - lack of provider continuity and the loss of skills from delegation of tasks. CONCLUSION: Family physicians perceive both benefits and risks to interprofessional team-based care in caring for patients with T2DM. Successful functioning of team-based care in family practice will require overcoming traditional professional roles.

Discharging the complex patient - changing our focus to patients' networks of care providers.

BACKGROUND: A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning. METHODS: This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical. RESULTS: We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network's scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial. CONCLUSIONS: Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support.

Intimidation, harassment, and discrimination during family medicine residency training: a mixed methods study.

BACKGROUND: The importance of wellbeing of family medicine residents is recognized in accreditation requirements which call for a supportive and respectful learning environment; however, concerns exist about learner mistreatment in the medical environment. The purpose of this study was to to describe family medicine graduates' perceived experience with intimidation, harassment and discrimination (IHD) during residency training. METHODS: A mixed-methods study was conducted on a cohort of family medicine graduates who completed residency training during 2006-2011. Phase 1, the quantitative component, consisted of a retrospective survey of 651 graduates. Phase 2, the qualitative component, was comprised of 11 qualitative interviews. Both the survey and the interviews addressed graduates' experience with IHD with respect to frequency and type, setting, perpetrator, perceived basis for IHD, and the effect of the IHD. RESULTS: The response rate to the survey was 47.2%, with 44.7% of respondents indicating that they experienced some form of mistreatment/IHD during residency training, and 69.9% noting that it occurred more than once. The primary sources of IHD were specialist physicians (75.7%), hospital nurses (47.8%), and family physicians (33.8%). Inappropriate verbal comments were the most frequent type of IHD (86.8%). Graduates perceived the basis of the IHD to be abuse of power (69.1%), personality conflict (36.8%), and family medicine as a career choice (30.1%), which interview participants also described. A significantly greater proportion IMGs than CMGs perceived the basis of IHD to be culture/ethnicity (47.2% vs 10.5%, respectively). The vast majority (77.3%) of graduates reported that the IHD experience had a negative effect on them, consisting of decreased self-esteem and confidence, increased anxiety, and sleep problems. As trainees, they felt angry, threatened, demoralized, discouraged, manipulated, and powerless. Some developed depression or burnout, took medication, or underwent counselling. CONCLUSIONS: IHD continued to be prevalent during family medicine residency training, with it occurring most frequently in the hospital setting and specialty rotations. Educational institutions must work with hospital administrators to address issues of mistreatment in the workplace. Residency training programs and the medical establishment need to be cognizant that the effects of IHD are far-reaching and must continuously work to eradicate it.

Developing a Decision-Making Capacity Assessment Clinical Pathway for Use in Primary Care: a Qualitative Exploratory Case Study.

BACKGROUND: With an ageing population, the incidence of dementia will increase, as will the number of persons requiring decision-making capacity assessments. For over 10 years, we have trained family physicians in conducting decision-making capacity assessments. Physician feedback post-training, however, has highlighted the need to integrate the decision-making capacity assessment process into the primary care context. The purpose of this study was to develop a decision-making capacity assessment clinical pathway for implementation in primary care. METHODS: A qualitative exploratory case-study design was used to obtain participants' perspectives regarding the utility of a visual algorithm detailing a decision-making capacity assessment clinical pathway for use in primary care. Three focus groups were conducted with family physicians (n=4) and allied health professionals (n=6) in two primary care clinics in Alberta. A revised algorithm was developed based on their feedback. RESULTS: In the focus groups, participants identified inconsistencies and a lack of standardization regarding decision-making capacity assessments within primary care, and provided feedback regarding a decision-making capacity assessment clinical pathway to make it more applicable to primary care. Participants described this pathway as appealing and straightforward; they also made suggestions to make it more primary care-centric. Participants indicated that the presented pathway would improve teamwork and standardization of decision-making capacity assessments within primary care. CONCLUSIONS: Use of a decision-making capacity assessment clinical pathway has the potential to standardize decision-making capacity assessment processes in primary care, and support least intrusive and least restrictive patient outcomes for community-dwelling older adults.

Factors perceived to influence rural career choice of urban background family physicians: A qualitative analysis.

BACKGROUND: Urban background physicians are the main source of physician supply for rural communities across Canada. The purpose of this study was to describe factors that are perceived to influence rural career choice and practice location of urban background family medicine graduates. METHODS: We conducted a qualitative, descriptive study employing telephone interviews with 9 urban background family physicians practicing in rural locations. Those who completed residency training between 2006 and 2011, were in rural practice, and had an urban upbringing were asked: when the decision for rural practice was made; factors that influenced rural career choice; and factors that influenced choice of a particular rural location. Emerging themes were identified through content analysis of interview data. RESULTS: We identified four themes as factors perceived to influence rural career choice - variety/broad scope of rural practice, rural lifestyle, personal relationships, and positive rural experience/physician role models. We also identified factors in four areas perceived to influence the choice of a particular rural practice location - having lived in the rural community, spousal influence, personal lifestyle, and comfort with practice expectations. CONCLUSION: Decisions for rural career choice and rural practice location by practicing urban background family medicine graduates are based on clinical practice considerations, training experience, as well as personal and lifestyle factors.

CONTEXTE: Les médecins provenant d'un milieu urbain représentent la principale source de médecins pour les communautés rurales au Canada. Cette étude vise à décrire les facteurs qui sont perçus comme influençant un choix de carrière en milieu rural pour les diplômés en médecine familiale provenant d'un milieu urbain. MÉTHODES: Nous avons mené une analyse qualitative et descriptive à l'aide d'entrevues téléphoniques avec neuf diplômés en médecine familiale provenant d'un milieu urbain. On posait les questions suivantes à ceux qui avaient terminé leur résidence entre 2006 et 2011, qui pratiquaient en milieu rural et qui avaient grandi en milieu urbain : à quel moment la décision de s'établir en milieu rural a-t-elle été prise? Quels sont les facteurs qui ont influencé le choix de carrière en milieu rural? Quels facteurs ont influencé le choix d'un emplacement rural particulier. Les thèmes émergents ont été relevés par l'analyse du contenu des données d'entrevue. RÉSULTATS: Nous avons répertorié quatre thèmes comme facteurs perçus pour influencer le choix d'une carrière en milieu rural : la variété et la portée élargie d'une pratique en milieu rural, le style de vie rural, les relations personnelles et des expériences rurales positives/modèles de rôle de médecin en milieu rural. Nous avons également relevé quatre thèmes perçus pour influencer le choix de s'établir dans un milieu rural particulier : avoir vécu dans cette communauté rurale, l'influence du conjoint, le style de vie personnel et se sentir à l'aise avec les attentes de ce milieu de pratique. CONCLUSION: Les décisions d'un choix de carrière en milieu rural par des diplômés en médecine familiale provenant d'un milieu urbain et maintenant en pratique, sont fondées sur des considérations de pratique clinique, l'expérience de la formation ainsi que des facteurs personnels et de style de vie.

Improving transitions from acute care to home among complex older adults using the LACE Index and care coordination.

BACKGROUND: Improving transitions in care is a major focus of healthcare planning. The objective of this study was to determine the improvement in transitions from an intervention identifying complex older adult patients in acute care and supporting their discharge into the community. METHODS: This was a quality assurance study evaluating an intervention on high-risk patients admitted in an acute care hospital. In phase 1, the Length of Stay, Acuity of the Admission, Charlson Comorbidity Index Score, and Emergency Department Use (LACE Index) was selected to assess a patient's risk for readmission and a standard discharge protocol was developed. In phase 2, the intervention was implemented: (1) all patients were screened for the risk of readmission using the LACE Index; and (2) the high-risk patients were provided care coordination including follow-up phone calls focused on medications, equipment and homecare services. Emergency department (ED) revisits and hospital readmissions were measured. RESULTS: The LACE Index identified 433/1621 (27%) patients at high risk for readmission. Care coordination was achieved within 72 hours in 79% of patients. The 433 high-risk patients receiving the intervention, compared with a group without intervention (n=231), had lower lengths of stay (12.7 days vs 16.6 days); similar 7-day ED revisits (10.6% vs 10.8%) and 30-day ED revisits (30.5% vs 33.3%); lower 90-day readmissions (39.3% vs 44.6%); and lower 6-month readmissions (50.9% vs 58.4%). The 7-day and 30-day readmissions were similar in both groups. CONCLUSIONS: Identifying complex patients at high risk for readmission and supporting them during transitions from acute care to home potentially decreases lengths of hospital stay and prevents short-term ED revisits and long-term readmissions.

Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care.

PURPOSE: The authors previously found that attending physicians conceptualize hospital admission purpose according to 3 perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams. METHOD: Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis. RESULTS: The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge focused vs optimization focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspectives, using authority to shut down and redirect discussion. Trainees' maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover). CONCLUSIONS: Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and to trainees participating in covert maneuvers, potentially affecting trust and professional identify development.

Interprofessional collaboration in diabetes care: perceptions of family physicians practicing in or not in a primary health care team.

BACKGROUND: In Canada, most patients with type 2 diabetes mellitus (T2DM) are cared for in the primary care setting in the practices of family physicians. This care is delivered through a variety of practice models ranging from a single practitioner to interprofessional team models of care. This study examined the extent to which family physicians collaborate with other health professionals in the care of patients with T2DM, comparing those who are part of an interprofessional health care team called a Primary Care Network (PCN) to those who are not part of a PCN. METHODS: Family physicians in Alberta, Canada were surveyed to ascertain: which health professionals they refer to or have collaborative arrangements with when caring for T2DM patients; satisfaction and confidence with other professionals' involvement in diabetes care; and perceived effects of having other professionals involved in diabetes care. Chi-squared and Fishers Exact tests were used to test for differences between PCN and non-PCN physicians. RESULTS: 170 (34%) family physicians responded to the survey, of whom 127 were PCN physicians and 41 were non-PCN physicians (2 not recorded). A significantly greater proportion of PCN physicians vs non-PCN physicians referred patients to pharmacists (23.6% vs 2.6%) or had collaborative working arrangements with diabetes educators (55.3% vs 18.4%), dietitians (54.5% vs 21.1%), or pharmacists (43.1% vs 21.1%), respectively. Regardless of PCN status, family physicians expressed greater satisfaction and confidence in specialists than in other family physicians or health professionals in medication management of patients with T2DM. Physicians who were affiliated with a PCN perceived that interprofessional collaboration enabled them to delegate diabetes education and monitoring and/or adjustment of medications to other health professionals and resulted in improved patient care. CONCLUSIONS: This study sheds new insight on the influence that being part of a primary care team has on physicians' practice. Specifically, supporting physicians' access to other health professionals in the primary care setting is perceived to facilitate interprofessional collaboration in the care of patients with T2DM and improve patient care.

Leadership Development in Postgraduate Medical Education: A Systematic Review of the Literature.

PURPOSE: To evaluate and interpret evidence relevant to leadership curricula in postgraduate medical education (PGME) to better understand leadership development in residency training. METHOD: The authors conducted a systematic review of peer-reviewed, English-language articles from four databases published between 1980 and May 2, 2017 that describe specific interventions aimed at leadership development. They characterized the educational setting, curricular format, learner level, instructor type, pedagogical methods, conceptual leadership framework (including intervention domain), and evaluation outcomes. They used Kirkpatrick effectiveness scores and Best Evidence in Medical Education (BEME) Quality of Evidence scores to assess the quality of the interventions. RESULTS: Twenty-one articles met inclusion criteria. The classroom setting was the most common educational setting (described in 17 articles). Most curricula (described in 13 articles) were isolated, with all curricula ranging from three hours to five years. The most common instructor type was clinical faculty (13 articles). The most commonly used pedagogical method was small group/discussion, followed by didactic teaching (described in, respectively, 15 and 14 articles). Study authors evaluated both pre/post surveys of participant perceptions (n = 7) and just postintervention surveys (n = 10). The average Kirkpatrick Effectiveness score was 1.0. The average BEME Quality of Evidence score was 2. CONCLUSIONS: The results revealed that interventions for developing leadership during PGME lack grounding conceptual leadership frameworks, provide poor evaluation outcomes, and focus primarily on cognitive leadership domains. Medical educators should design future leadership interventions grounded in established conceptual frameworks and pursue a comprehensive approach that includes character development and emotional intelligence.