Nurse-doctor co-teaching: A path towards interprofessional collaboration.

BACKGROUND: Nurse-doctor collaborations are essential for team-based patient care. Although there are increasing calls for interprofessional education, teaching and learning together is rare. In 2019, we designed a Nurse-Doctor Co-Teaching pilot programme to provide an opportunity for nurses and doctors to co-teach junior doctors and nurses. We aimed to explore the experiences of the co-teachers and understand their perceptions of teaching together. The study was conducted through the lens of positioning theory. METHODS: We held an hour-long focus group discussion and follow-up one-on-one interviews with nurses and doctors who participated as co-teachers. Conversations were audio-video recorded, transcribed, and thematically analysed. The Partners Institutional Review Board approved this study. RESULTS: Three nurses and four doctors participated in the focus group conversation, and four nurses and two doctors participated in individual interviews. Participant narratives provided insight into shifts in hospital culture that would be necessary to promote effective interprofessional learning and collaboration: (1) break down professional silos, (2) invite the nursing perspective, (3) flatten professional hierarchies, and (4) recognise nurses as clinical teachers. CONCLUSION: Nurses and doctors felt they shared a collegial and equal partnership as co-teachers. But this relationship was not typical of their daily clinical roles. Institutional barriers presented challenges to collaboration on the hospital floor and nursing participation in teaching. Successful interprofessional education may require culture and policy shifts that formally recognise nurses as valuable clinical teachers.

Putting the Heme Back in Heme-Onc: an Evaluation of the Redesigned Hematology Track within the Dana Farber/Mass General Brigham Hematology-Oncology Fellowship.

In 2019, the Dana Farber/Mass General Brigham Hematology-Oncology Fellowship redesigned the 6-month Hematology training track/curriculum required for all fellows seeking to double board in hematology and oncology. Responding to both national and local trends suggesting a future shortage of hematologists, the goal of the redesign was to create a new curriculum that would increase fellow interest in hematology, improve fellows' clinical knowledge of hematology, and serve as an example to other Hematology-Oncology programs across the country. The revised track has now been in place for four years, and, in this paper, the authors present the fellow experience with the first four years of the redesigned curriculum. Based on the number of fellows who chose to complete the new curriculum, as well as the fellow evaluations and performance on the Hematology In-Training Exam, the authors conclude that the new curriculum has successfully increased both fellow interest in and knowledge of hematology.

Agreement of Nurses' and Physicians' Attitudes on Collaboration During the Covid-19 Pandemic Using the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration.

Background: Collaboration between physicians and nurses has been shown to lead to better patient outcomes. However, studies have shown differing physicians' and nurses' responses to survey questions about physician-nurse collaboration. We surveyed physicians and nurses during the Covid-19 pandemic for their attitudes toward collaboration. Methods: In August 2021, during the Covid-19 pandemic, we surveyed physicians and nurses throughout an urban, academic teaching hospital over a consecutive twenty-day period using the validated Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration. Anonymous surveys were obtained from nurses and physicians on duty at the hospital. Demographic data from each survey included gender, age, profession of nurse or physician, degree, and specialization. Results: Four hundred and fifteen (415) unique paper surveys were collected from 308 nurses and 107 physicians over the twenty-day period. Five nurses and two physicians declined to complete the survey (1.6%). Using the Independent t-test of Means, total score and sub-scores were analyzed. Physicians and nurses scored the paper surveys in a similar manner. No statistically significant differences between the scores of physicians and nurses were found for any of the fifteen Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration questions, except for the youngest age group (20-29-year-old) having a significantly more positive response to doctors being the dominant authority on all health matters (p-value=0.011). Gender and nursing degree did not make a significant difference. Surgical Specialties (167), Medical Specialties (196), Intensive Care Unit (21), and the Emergency Department (43) survey responses did not differ significantly from each other. Conclusion: One and a half years into the Covid-19 pandemic, physicians and nurses at an urban, academic teaching hospital were in agreement with their responses on the validated Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration. Our data may reflect a catalytic and positive effect of the Covid-19 pandemic on physician and nurse attitudes toward collaboration.

Impact of Extended Duty Hours on Perceptions of Care and Objective Patient Outcomes.

OBJECTIVE: In 2017, interns were permitted to work continuously for up to 28 hours at a time, a reversal from the previously mandated 16-hour limit. Our objective was to evaluate perceptions of care and patient outcomes on an extended (28-hour) compared with a limited (16-hour) duty-hour system on identical interdisciplinary teams. METHODS: Sixty-two interns, 27 residents, 28 attendings, and 449 patients participated. Patients completed surveys assessing their satisfaction. Anonymous weekly surveys were obtained from interns, residents, and attendings evaluating perceptions of intern tiredness, overall satisfaction, and performance. Nursing surveys evaluated intern and medical team performance. Objective outcome measures, including intensive care unit transfers, length of stay, readmissions, mortality, and complications, were assessed through a retrospective, blinded chart review. RESULTS: Patients reported similar satisfaction in care. Extended duty-hour interns reported significantly decreased familiarity with their patients, decreased ability to conduct physical exams on new patients, increased tiredness, and decreased overall satisfaction. Residents overseeing extended-duty interns reported significantly decreased quality in intern presentations and overall quality of teaching, and increased perception of intern tiredness and increased incorrect orders. Attending physicians reported significantly improved quality of new patient presentations by extended duty-hour interns. No significant differences in patient objective outcome measures were noted. CONCLUSIONS: Extended intern duty hours do not affect patient's satisfaction with their care. Although interns in the extended duty-hour system reported significantly increased fatigue and decreased overall satisfaction and residents' perceived increases in incorrect intern orders in the extended duty-hour system, there were no detrimental effects on patient safety.

Nurse-Doctor Co-Teaching: A Pilot Study of the Design, Development, and Implementation of Structured Interprofessional Co-Teaching Sessions.

INTRODUCTION: High levels of interprofessional collaboration are beneficial for patients and healthcare providers. Co-teaching may be one method for creating a collaborative environment. This pilot study designed, developed, and implemented Nurse-Doctor Co-Teaching on an inpatient medicine service. METHODS: Ten Nurse-Doctor Co-Teaching pairs designed 30-minute, structured co-teaching sessions with learning objectives, evidence-based content, interactive teaching strategies and a Take-Away of key content with the help of a coaching team. Each session was presented by a nurse and senior doctor to nurse and resident learners. Our assessment blueprint included: 1. Anonymous surveys assessing the overall rating of each session and 2. Pre- and post-anonymous surveys assessing measures of interprofessional collaboration and communication between nurses and residents before and after the series of ten co-teaching sessions. RESULTS: Data from ten post-session surveys included 121 of 156 participants (77.6%). Attendance at each session ranged from 13-19 participants with 8-17 participants completing a survey per session for an average of 12.1 surveys analyzed. All Nurse-Doctor Co-Teaching sessions scored in the excellent range between 1.00 and 1.43 on a Likert scale (1 is excellent and 5 is poor). In response to the question "What did you like best?", interactive teaching strategies was the most frequent spontaneous answer. A significant correlation between the number of interactive teaching strategies and enjoyability of the session (p-value=0.01) was observed. Measures of interprofessional collaboration and communication did not change significantly in the pre-intervention compared to post-intervention period. CONCLUSION: We created a unique model of interprofessional co-teaching on an inpatient service. The overall excellent ratings of our interactive sessions indicate that Nurse-Doctor Co-Teaching is a valued form of learning. Our structured format is adaptable to various medical settings and could be expanded to include additional allied health professionals. We plan further studies to assess if Nurse-Doctor Co-Teaching improves measures of interprofessional collaboration.

Optimizing Multidisciplinary Simulation in Medical School for Larger Groups: Role Assignment by Lottery and Guided Learning.

PURPOSE: Medical school simulations are often designed for a limited number of students to maximize engagement and learning. To ensure that all first-year medical students who wished to join had an opportunity to participate, we designed a novel method for larger groups. PATIENTS AND METHODS: We devised a low technology "Orchestra Leader's" chart approach to prominently display students' roles, chosen by lottery. During simulation, the chart was mounted on an intravenous pole and served as a group organizational tool. A course instructor prompted students using the chart to accomplish the course objectives in a logical order. Real-life cardiologists and gastroenterologists provided the students with expert subspecialty consultation. We analyzed 125 anonymous student evaluation ratings for 3 years (2017-2019) with a range of 8 to 19 students per laboratory session. RESULTS: Our 2017-2019 larger group sessions were all rated as excellent (1.26, Mean, SD ±.510) on the Likert scale where 1.0 is excellent and 5.0 is poor. There were no statistically significant differences in overall ratings among the 2017, 2018 and 2019 sessions. The subspecialists were uniformly rated as excellent. Verbatim free-text responses demonstrated resounding student appreciation for the role assignment by lottery method. CONCLUSION: We designed a novel, "Orchestra Leader's" chart approach for accommodating larger groups in a multidisciplinary simulation laboratory using role assignment by lottery, roles depicted on an organizational chart, and expert instructor prompting. Our consistently excellent ratings suggest that our methods are useful for achieving well-rated larger group simulation laboratories.

Is Asking Questions on Rounds a Teachable Skill? A Randomized Controlled Trial to Increase Attendings' Asking Questions.

BACKGROUND: Morning bedside rounds remain an essential part of Internal Medicine residency education, but rounds vary widely in terms of educational value and learner engagement. OBJECTIVE: To evaluate the efficacy of an intervention to increase the number and variety of questions asked by attendings at the bedside and assess its impact. DESIGN: We conducted a randomized, controlled trial to evaluate the efficacy of our intervention. PARTICIPANTS: Hospitalist attendings on the general medicine service were invited to participate. Twelve hospitalists were randomized to the experimental group and ten hospitalists to the control group. INTERVENTION: A one-hour interactive session which teaches and models the method of asking questions using a non-medical case, followed by practice using role plays with medical cases. MAIN MEASURES: Our primary outcome was the number of questions asked by attendings during rounds. We used audio-video recordings of rounds evaluated by blinded reviewers to quantify the number of questions asked, and we also recorded the type of question and the person asked. We assessed whether learners found rounds worthwhile using anonymous surveys of residents, patients, and nurses. KEY RESULTS: Blinded analysis of the audio-video recordings demonstrated significantly more questions asked by attendings in the experimental group compared to the control group (mean number of questions 23.5 versus 10.8, p< 0.001) with significantly more questions asked of the residents (p<0.003). Residents rated morning bedside rounds with the experimental attendings as significantly more worthwhile compared to rounds with the control group attendings (p=0.009). CONCLUSION: Our study findings highlight the benefits of a one-hour intervention to teach faculty a method of asking questions during bedside rounds. This educational strategy had the positive outcome of including significantly more resident voices at the bedside. Residents who rounded with attendings in the experimental group were more likely to "strongly agree" that bedside rounds were "worthwhile".

Case-Based Curriculum With Integrated Smartphone Applications Improves Internal Medicine Resident Knowledge Of Contraceptive Care.

BACKGROUND: Contraception is an essential preventive service for all women. However, the literature suggests that internal medicine residents have low levels of confidence and knowledge of contraceptive care. OBJECTIVE: We designed and implemented a novel contraception curriculum promoting active, collaborative learning. We sought to evaluate whether this curriculum improved internal medicine resident knowledge of and comfort with contraceptive care through the administration of pre-/post-surveys. METHODS: Our curriculum was delivered in a two-hour session as part of the mandatory ambulatory curriculum for internal medicine interns at our institution in the academic year 2017-2018. Interns were provided with select online resources and two smartphone applications at the beginning of the session, which they then used in case-based small group work. Small group work was followed by a large group case review, co-facilitated by OB/GYN and internal medicine faculty. RESULTS: Thirty-eight participants completed surveys assessing knowledge of and comfort with contraceptive care immediately before and after the curriculum; 20 participants completed surveys assessing the same domains 4-6 months after the curriculum. Data from surveys administered immediately post-curriculum demonstrated significant improvements in knowledge about and comfort with counseling about, assessing medical eligibility for, and initiating multiple forms of contraception. Many of these improvements in knowledge and comfort were maintained on follow-up surveys 4-6 months following the curriculum. CONCLUSION: Our case-based curriculum with integrated smartphone applications resulted in significant improvements in internal medicine resident knowledge of and comfort with the key skills of contraceptive care. In contrast to active, collaborative learning methodologies such as the flipped classroom, our methodology supports active, collaborative learning without requiring advance learner preparation, and is thus well suited to the time constraints of the graduate medical education setting. Our methodology is readily translatable to other clinical topics and residency curricula.

Health Care Use by Muslim Patients During Ramadan.

PURPOSE: Health care utilization during Ramadan has not been examined in the United States. METHODS: A retrospective review of billing and electronic health record data for Muslims (n = 2,919) and non-Muslims (n = 184,803) in primary care practices in Eastern Massachusetts. RESULTS: Muslim patients were younger, less educated, less often commercially insured, more likely to have Medicare, and less likely to be primary English speakers (p < .0001 for all comparisons). In multivariate models, during Ramadan, Muslims, compared with non-Muslims, had a higher rate of primary care visits (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 1.01-1.11), emergency department visits (IRR, 1.60; 95% CI, 1.34-1.91), and hospitalizations (IRR, 1.18; 95% CI, 1.03-1.34). CONCLUSIONS: Important demographic differences exist between Muslim and non-Muslim patients. Muslims, compared with non-Muslims, had higher health care utilization during Ramadan.

Teaching methods used by internal medicine residents on rounds: what works?

BACKGROUND: The specific teaching methods used by internal medicine residents on walk rounds are unknown. OBJECTIVES: 1) To characterize in real time the specific teaching methods used by internal medicine residents on rounds and 2) to identify attributes of successful resident teaching on rounds. MATERIALS AND METHODS: We conducted a prospective mixed-methods study on inpatient medical services at a single academic medical center from September 2016 to January 2017. Participants were internal medicine residents (postgraduate year [PGY]-1, PGY-2, and PGY-3) and attending physicians. Teachers were PGY-2 and PGY-3 residents, and learners were PGY-1 residents. Residents' teaching on rounds was observed and characterized according to resident demographics, specific teaching methods, and length of time. Participants completed a survey with Likert scale and free-text questions. RESULTS AND CONCLUSION: Among 136 surveys across 28 separate teaching encounters, we noted that PGY-3 residents' teaching was rated significantly better than PGY-2 residents' teaching. Teaching lasting >1 minute was rated significantly better than teaching lasting <1 minute. Free-text responses emphasized the value of immediate clinical relevance, citing published evidence, conciseness, clarity, and pertinence to the patient. Our findings may help guide internal medicine residents aiming to teach better on rounds and inform further research into specific resident teaching methods.

Scope of Burnout Among Young Gastroenterologists and Practical Solutions from Gastroenterology and Other Disciplines.

Burnout is a critical issue among physicians, including gastroenterologists. Up to 50% of gastroenterologists have reported symptoms of burnout in national assessments, leading to increased recognition of the burden of burnout among subspecialty societies. Particularly alarming in these assessments of burnout is the suggestion of increased rates of burnout among trainees and early career gastroenterologists. In this article, we describe the scope of burnout among young gastroenterologists and the risk factors that contribute. In addition, we will offer practical solutions to reduce burnout based on insights developed from multidisciplinary approaches, including relevant burnout literature, organizational approaches within academic medical centers, and training programs, as well as interviews with successful private practice gastroenterologists, and leaders in the fields of business and education.

Two Cases of Acute Cholecystitis and Symptomatic Choledocholithiasis in Two Women Less than 40-Years-of-Age with Hormonal Intrauterine Devices.

Levonorgestrel uterine implants are accepted as a safe and efficacious method of contraception. One of the two major health side effects in a large controlled study of subcutaneous hormonal implants with levonorgestrel was a significant increase in gallbladder disease. Gallbladder hypomotility is recognized as a side effect of the levonorgestrel (progesterone). We recently saw on a Gastroenterology Consult Service, two women under 40-years-of-age who had been transferred from outside hospitals with acute cholecystitis with symptomatic choledocholithiasis. Both required Endoscopic Retrograde Cholangiopancreatography and sphincterotomies in addition to laparoscopic cholecystectomies. Both had hormonal (levonorgestrel-releasing) intrauterine devices in place for contraception. Although one patient had a family history of gallstones, the other did not. Both were nonobese, young women patients. We were struck by the coincidence of seeing two such patients. Few articles in the medical literature detail the clinical risks of gallstone disease in patients with hormonal (levonorgestrel-releasing) intrauterine devices. Our experiences with these two patients led us to believe that patients with risk factors for gallstone disease, such as a positive family history, ethnic predisposition, or obesity, should be warned of possible problems, not only with gallbladder disease, but also of common duct stones.

Asking what do residents value most: a recent overview of internal medicine residents' learning preferences.

BACKGROUND: Little is known about the preferred learning experiences of today's internal medicine residents. We conducted a survey of the educational experiences in an internal medicine residency to determine the learning opportunities internal medicine residents value most and why. METHODS: An online, anonymous survey of 182 internal medicine residents was performed, with each resident receiving a survey each day over nine days. Participants were asked to state their most valuable learning experience over the past day, describe why it was valuable, and rank it on a 5-point Likert-type scale. Resident free-text responses were coded and grouped into themes. The location of and participants in the experience were also examined. RESULTS: The 182 residents completed a total of 303 surveys. Of the 303 surveys, 92% (N=277) of the responses noted their chosen learning experience was useful. An attending was involved in 50% (N=152) of experiences; the patient was noted as a participant in 8% (N=25) of experiences. Free-text responses were coded into five thematic groups descriptive of why residents found their learning experiences to be valuable: Repetition in Learning, Effective Pedagogy, Clinical Problem Solving as an Individual or Collaboratively, Opportunity for Active Engagement, and Bedside Learning. CONCLUSION: Our data provide a broader framework for designing and implementing future faculty development and resident curricula that emphasize interprofessional education and the patient as a key educational figure.

Asking a Variety of Questions on Walk Rounds: a Pilot Study.

BACKGROUND: Morning walk rounds have lost some of their engagement while remaining a useful and valued practice. AIM: We created a pilot study to evaluate the impact on rounds of learning to asking a variety of different questions. SETTING: One-hour intervention sessions were voluntarily offered to members of the Department of Medicine and taught by an expert in the question, listen, and respond method. PARTICIPANTS: Participants included attendings and residents in Internal Medicine on medical teams. PROGRAM DESCRIPTION: Questionnaires were collected on six pre-intervention and six post-intervention days. Nine months later, an anonymous online survey was sent to participants asking about their use of a wider variety of questions. PROGRAM EVALUATION: Two hundred eight physicians (residents 175 (45.5%), attending physicians 25 (27.7%)) filled out pre-intervention surveys. One hundred eighty-one physicians (residents 155 (40.3%), attending physicians 18 (20%)) filled out post-intervention surveys. When survey responses from the attendings and residents on the medical teams were combined, post-intervention rounds were perceived as more worthwhile (1.99 pre-intervention and 1.55 post-intervention, [95% confidence interval 1.831-2.143]) (p < 0.001) and more engaging (1.68 pre-intervention and 1.30 post-intervention, [95% confidence interval 1.407-1.688]) (p < 0.001).Non-medical teams' survey responses did not change. Patient census data indicated no significant difference in the hospital's census on the pre- and post-intervention dates. Spontaneous suggestions for improving rounds came largely from the residents and included teaching points, clinical pearls, patient focus, more interactive, increased dedicated time for teaching, inclusive/multidisciplinary, questions, and evidence-based teaching. Of the participants who answered the online survey 9 months later, 75% (6/8) reported that they "actually asked a wider variety of types of questions." DISCUSSION: This pilot study indicates that the 1-h intervention of learning to ask a variety of different questions is associated with rounds that are rated as more worthwhile and engaging by the medical teams.

Volunteer patients and small groups contribute to abdominal examination's success.

BACKGROUND: Prior to 2007, we taught the abdominal examination in a hospital based group to 40 students, at one hospital. We used volunteer patients, small groups, repetition, and required faculty development sessions. In 2007, our medical school changed its "Introduction to Physical Examination" session so that the entire class was to be taught in a geographically central session. Our hospital was selected to lead the abdominal examination portion of the session. AIM: Our aim was to answer three questions. First, could we quadruple the recruitment of volunteer patients, and faculty? Second, was it volunteer patients, small groups, repetition, or faculty training that was most valued by the students? Third, would volunteer patients and/or faculty agree to participate a second time? METHODS: A total of 43-46 patients and 43-46 faculty were recruited and 43-46 examining rooms were obtained for each of the 5 years of this study. Teachers were required to attend a 1-hour faculty development session. The class of about 170 students was divided into 43-46 groups each year. The teacher demonstrated the abdominal examination and each student practiced the examination on another student. Each student then repeated the full abdominal examination on a volunteer patient. RESULTS: Over the 5-year time period (2008-2012), the abdominal examination ranked first among all organ systems' "Introductory Sessions". The abdominal examination ratings had the best mean score (1.35) on a Likert scale where 1 is excellent and 5 is poor. The students gave the most positive spontaneous comments to having volunteer patients, with small groups coming in as the second most appreciated educational element. CONCLUSION: We successfully quadrupled the number of faculty, patients, and examining rooms and created a highly rated educational program as measured by anonymous student evaluations, patient and faculty participation, and the medical school's selecting the abdominal examination methods as an "Advanced Examination" for the Pathways Curriculum.

An active learning curriculum improves fellows' knowledge and faculty teaching skills.

OBJECTIVES: Traditional didactic lectures are the mainstay of teaching for graduate medical education, although this method may not be the most effective way to transmit information. We created an active learning curriculum for Brigham and Women's Hospital (BWH) gastroenterology fellows to maximize learning. We evaluated whether this new curriculum improved perceived knowledge acquisition and knowledge base. In addition, our study assessed whether coaching faculty members in specific methods to enhance active learning improved their perceived teaching and presentation skills. METHODS: We compared the Gastroenterology Training Exam (GTE) scores before and after the implementation of this curriculum to assess whether an improved knowledge base was documented. In addition, fellows and faculty members were asked to complete anonymous evaluations regarding their learning and teaching experiences. RESULTS: Fifteen fellows were invited to 12 lectures over a 2-year period. GTE scores improved in the areas of stomach (p<0.001), general gastroenterology (p=0.005), esophagus (p<0.001), and small bowel (p=0.001), and the total score (p=0.001) between pre- and postimplementation of the active learning curriculum. Scores in hepatology, as well as biliary and pancreatic study, showed a trend toward improvement (p>0.05). All fellows believed the lectures were helpful, felt more prepared to take the GTE, and preferred the interactive format to traditional didactic lectures. All lecturers agreed that they acquired new teaching skills, improved teaching and presentation skills, and learned new tools that could help them teach better in the future. CONCLUSION: An active learning curriculum is preferred by GI fellows and may be helpful for improving transmission of information in any specialty in medical education. Individualized faculty coaching sessions demonstrating new ways to transmit information may be important for an individual faculty member's teaching excellence.

Innovative curriculum for second-year Harvard-MIT medical students: practicing communication skills with volunteer patients giving immediate feedback.

PURPOSE: Medical students are expected to develop excellent communication skills. The purpose of our study was to create an innovative communication skills exercise using real volunteer patients and physician co-teachers for students to practice communication skills while receiving immediate feedback. METHOD: This is a mixed methods study where second-year medical students participated in the communication skills exercise with real patients and physician co-teachers giving immediate feedback. Clinical scenarios reflected the patients' actual experiences. Students acted out roles as physicians. Physicians co-taught with the patients and gave immediate feedback to students. Students completed an anonymous written survey at the end of the exercise. Qualitative and quantitative responses were recorded. Student feedback from the 2014 surveys was used to modify the teaching designs to increase active role play opportunities by having only two students in each group and doubling the number of stations with real patients. RESULTS: Students rated the overall exercise and the utility of patient volunteers in learning how to communicate on a Likert scale of 1-5, where in this medical school traditionally 1 is excellent and 5 is poor. In 2014, the exercises were rated with a mean score of 1.47 (SD 0.621). In 2015, the exercises were rated with a mean score of 1.03 (SD 0.62). In 2016, the exercises were rated with a mean score of 1.27 (SD 0.52). ANOVA analysis (p=0.002) and Bonferroni corrections indicate a statistically significant difference between combined mean scores of the exercise in 2014 and 2015 (p=0.001). No difference was shown between 2014 and 2016 or 2015 and 2016. CONCLUSIONS: Medical students rated practicing communication skills with real patient volunteers and physician co-teachers giving immediate feedback in their preclinical years very highly. Student feedback indicated that they preferred active roles and increased opportunities to practice their communication skills.