Mitigating Moral Injury for Palliative Care Clinicians.

Palliative care clinicians (PCCs) in the United States face the combination of increasing burnout and a growing need for their services based on demographic changes and an increasing burden of serious illness. In addition to efforts to increase the number of PCCs and to train other clinicians in "primary palliative skills," we must address the burnout in the field to address the growing gap between need for this care and capacity to provide it. To address burnout in PCCs, we must develop solutions with the unique contributors to burnout in this field in mind. PCCs are particularly susceptible to moral distress and moral injury faced by all clinicians, and these states are inextricably linked to burnout. We propose three solutions to address moral distress and moral injury in PCCs to reduce burnout. These solutions are grounded in the dilemmas particular to palliative care and in best evidence: first, to create space for PCCs to confront moral challenges head-on; second, to integrate ethics consultations into care of some patients cared for by PCCs; and third, to reassess care models for PCCs. These approaches can mitigate burnout and thus address the growing gap in our ability to provide high-quality palliative care for those patients in need.

Compliance with CDIM-APDIM Guidelines for Department of Medicine Letters: an Opportunity to Improve Communication Across the Continuum.

BACKGROUND: With rising applications to internal medicine programs and pending changes in United States Medical Licensing Examination Step 1 score reporting, program directors desire transparent data for comparing applicants. The Department of Medicine Letters of Recommendation (DOM LORs) are frequently used to assess applicants and have the potential to provide clearly defined data on performance including stratification of a medical school class. Despite published guidelines on the expected content of the DOM LOR, these LORs do not always meet that need. OBJECTIVES: To better understand the degree to which DOM LORs comply with published guidelines. METHODS: We reviewed DOM LORs from 146 of 155 LCME-accredited medical schools in the 2019 Match cycle, assessing for compliance with published guidelines. RESULTS: Adherence to the recommendation for DOM LORs to provide a final characterization of performance relative to peers was low (68/146, 47%). Of those that provided a final characterization, 19/68 (28%) provided a quantitative measure, and 49/68 (72%) provided a qualitative descriptor. Only 17/49 (35%) with qualitative terms described those terms, and thirteen distinct qualitative scales were identified. Ranking systems varied, with seven different titles given to highest performers. Explanations about determination of ranking groups were provided in 12% of cases. CONCLUSIONS: Adherence to published guidelines for DOM LORs varies but is generally low. For program directors desiring transparent data to use in application review, clearly defined data on student performance, stratification groupings, and common language across schools could improve the utility of DOM LORs.

Building a Shared Mental Model of Competence Across the Continuum: Trainee Perceptions of Subinternships for Residency Preparation.

INTRODUCTION: Toward a vision of competency-based medical education (CBME) spanning the undergraduate to graduate medical education (GME) continuum, University of Minnesota Medical School (UMMS) developed the Subinternship in Critical Care (SICC) offered across specialties and sites. Explicit course objectives and assessments focus on internship preparedness, emphasizing direct observation of handovers (Core Entrustable Professional Activity, "EPA," 8) and cross-cover duties (EPA 10). METHODS: To evaluate students' perceptions of the SICC's and other clerkships' effectiveness toward internship preparedness, all 2016 and 2017 UMMS graduates in GME training (n = 440) were surveyed regarding skill development and assessment among Core EPAs 1, 4, 6, 8, 9, 10. Analysis included descriptive statistics plus chi-squared and Kappa agreement tests. RESULTS: Respondents (n = 147, response rate 33%) rated the SICC as a rotation during which they gained most competence among EPAs both more (#4, 57% rated important; #8, 75%; #10, 70%) and less explicit (#6, 53%; #9, 69%) per rotation objectives. Assessments of EPA 8 (80% rated important) and 10 (76%) were frequently perceived as important toward residency preparedness. Agreement between importance of EPA development and assessment was moderate (Kappa = 0.40-0.59, all surveyed EPAs). CONCLUSIONS: Graduates' perceptions support the SICC's educational utility and assessments. Based on this and other insight from the SICC, the authors propose implications toward collectively envisioning the continuum of physician competency.

Medical Student Workshop Improves Student Confidence in Working With Trained Medical Interpreters.

INTRODUCTION: Many physicians care for patients whose primary spoken language is not English, and these interactions present challenges in physician-patient communication. These challenges contribute to the significant health disparities experienced by populations with limited English proficiency (LEP). Using trained medical interpreters is an important step in addressing this problem, as it improves communication outcomes. Despite this, many medical education programs have little formal instruction on how to work effectively with interpreters. METHODS: To address this gap, we created an interactive workshop led by professional trained interpreters and faculty facilitators for medical students in their clinical years. Students were asked to evaluate the session based on relevance to their clinical experiences and helpfulness in preparing them for interactions with patients with LEP. RESULTS: Immediately after the session, students reported that the clinical scenarios presented were similar those seen on their clinical clerkships. They also reported increased confidence in their ability to work with interpreters. On later follow-up, students reported that the instruction helped prepare them for subsequent patient interactions that involved interpreters. CONCLUSION: A workshop is an effective method for improving medical student comfort and confidence when working with interpreters for populations with LEP.

Collaborating for Competency-A Model for Single Electronic Health Record Onboarding for Medical Students Rotating among Separate Health Systems.

BACKGROUND: Use of the electronic health record (EHR) is widespread in academic medical centers, and hands-on EHR experience in medical school is essential for new residents to be able to meaningfully contribute to patient care. As system-specific EHR training is not portable across institutions-even when the same EHR platform is used-students rotating across health systems are often required to spend time away from clinical training to complete each system's, often duplicative, EHR training regardless of their competency within the EHR. METHODS: We aimed to create a single competency-based Epic onboarding process that would be portable across all the institutions in which our medical students complete clinical rotations. In collaboration with six health systems, we created online EHR training modules using a systematic approach to curriculum development and created an assessment within the Epic practice environment. RESULTS: All six collaborating health systems accepted successful completion of the developed assessment in lieu of standard site-specific medical student EHR training. In the pilot year, 443 students (94%) completed the modules and assessment prior to their clinical training and successfully entered clinical rotations without time consuming, often repetitive onsite training, decreasing the cumulative time as student might be expected to engage in Epic onboarding as much as 20-fold. CONCLUSION: Medical schools with multisystem training sites with a single type of EHR can adopt this approach to minimize training burden for their learners and to allow them more time in the clinical setting with optimized access to the EHR.

Criterion-Based Assessment in a Norm-Based World: How Can We Move Past Grades?

In the United States, the medical education community has begun a shift from the Flexnerian time-based model to a competency-based medical education model. The graduate medical education (GME) community is substantially farther along in this transition than is the undergraduate medical education (UME) community.GME has largely adopted the use of competencies and their attendant milestones and increasingly is employing the framework of entrustable professional activities (EPAs) to assess trainee competence. The UME community faces several challenges to successfully navigating a similar transition. First is the reliance on norm-based reference standards in the UME-GME transition, comparing students' performance versus their peers' with grades, United States Medical Licensing Examination Step 1 and Step 2 score interpretation, and the structured Medical School Performance Evaluation, or dean's letter. Second is the reliance on proxy assessments rather than direct observation of learners. Third is the emphasis on summative rather than formative assessments.Educators have overcome a major barrier to change by establishing UME outcomes assessment criteria with the advent and general acceptance of the physician competency reference set and the Core EPAs for Entering Residency in UME. Now is the time for the hard work of developing assessments steeped in direct observation that can be accepted by learners and faculty across the educational continuum and can be shown to predict clinical performance in a much more meaningful way than the current measures of grades and examinations. The acceptance of such assessments will facilitate the UME transition toward competency-based medical education.

Competency-Based Medical Education in the Internal Medicine Clerkship: A Report From the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force.

As medical educators continue to redefine learning and assessment across the continuum, implementation of competency-based medical education in the undergraduate setting has become a focus of many medical schools. While standards of competency have been defined for the graduating student, there is no uniform approach for defining competency expectations for students during their core clerkship year. The authors describe the process by which an Alliance for Academic Internal Medicine task force developed a paradigm for competency-based assessment of students during their inpatient internal medicine (IM) clerkship. Building on work at the resident and fellowship levels, the task force focused on the development of key learning outcomes as defined by entrustable professional activities (EPAs) that were specific to educational experiences on the IM clerkship, as well as identification of high-priority assessment domains. The work was informed by a national survey of clerkship directors.Six key EPAs emerged: generating a differential diagnosis, obtaining a complete and accurate history and physical exam, obtaining focused histories and clinically relevant physical exams, preparing an oral presentation, interpreting the results of basic diagnostic studies, and providing well-organized clinical documentation. A model for assessment was proposed, with descriptors aligned to the scale of supervision and mapped to Accreditation Council for Graduate Medical Education domains of competence. The proposed paradigm offers a standardized template that may be used across IM clerkships, and which would effectively bridge competency evaluation in the clerkship to fourth-year assessment as well as eventual postgraduate training.

An Entrustable Professional Activity (EPA)-Based Framework to Prepare Fourth-Year Medical Students for Internal Medicine Careers.

The purpose of the fourth year of medical school remains controversial. Competing demands during this transitional phase cause confusion for students and educators. In 2014, the Association of American Medical Colleges (AAMC) released 13 Core Entrustable Professional Activities for Entering Residency (CEPAERs). A committee comprising members of the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine applied these principles to preparing students for internal medicine residencies. The authors propose a curricular framework based on five CEPAERs that were felt to be most relevant to residency preparation, informed by prior stakeholder surveys. The critical areas outlined include entering orders, forming and answering clinical questions, conducting patient care handovers, collaborating interprofessionally, and recognizing patients requiring urgent care and initiating that care. For each CEPAER, the authors offer suggestions about instruction and assessment of competency. The fourth year of medical school can be rewarding for students, while adequately preparing them to begin residency, by addressing important elements defined in the core entrustable activities. Thus prepared, new residents can function safely and competently in supervised postgraduate settings.

Important Skills for Internship and the Fourth-Year Medical School Courses to Acquire Them: A National Survey of Internal Medicine Residents.

PURPOSE: To obtain feedback from internal medicine residents, a key stakeholder group, regarding both the skills needed for internship and the fourth-year medical school courses that prepared them for residency. This feedback could inform fourth-year curriculum redesign efforts. METHOD: All internal medicine residents taking the 2013-2014 Internal Medicine In-Training Examination were asked to rank the importance of learning 10 predefined skills prior to internship and to use a dropdown menu of 11 common fourth-year courses to rank the 3 most helpful in preparing for internship. The predefined skills were chosen based on a review of the literature, a national subinternship curriculum, and expert consensus. Chi-square statistics were used to test for differences in responses between training levels. RESULTS: Of the 24,820 internal medicine residents who completed the exam, 20,484 (83%) completed the survey, had complete identification numbers, and consented to have their responses used for research. The three skills most frequently rated as very important were identifying when to seek additional help and expertise, prioritizing clinical tasks and managing time efficiently, and communicating with other providers around care transitions. The subinternship/acting internship was most often selected as being the most helpful course in preparing for internship. CONCLUSIONS: These findings indicate which skills and fourth-year medical school courses internal medicine residents found most helpful in preparing for internship and confirm the findings of prior studies highlighting the perceived value of subinternships. Internal medicine residents and medical educators agree on the skills students should learn prior to internship.

Burnout and Physical Activity in Minnesota Internal Medicine Resident Physicians.

BACKGROUND: Regular physical activity plays an important role in the amelioration of several mental health disorders; however, its relationship with burnout has not yet been clarified. OBJECTIVE: To determine the association between achievement of national physical activity guidelines and burnout in internal medicine resident physicians. METHODS: A Web-based survey of internal medicine resident physicians at the University of Minnesota and Hennepin County Medical Center was conducted from September to October 2012. Survey measures included the Maslach Burnout Inventory-Human Services Survey and the International Physical Activity Questionnaire. RESULTS: Of 149 eligible residents, 76 (51.0%) completed surveys, which were used in the analysis. Burnout prevalence, determined by the Maslach Burnout Inventory, was 53.9% (41 of 76). Prevalence of failure to achieve US Department of Health and Human Services physical activity guidelines was 40.8% (31 of 76), and 78.9% (60 of 76) of residents reported that their level of physical activity has decreased since they began medical training. Residents who were able to meet physical activity guidelines were less likely to be burned out than their fellow residents (OR, 0.38, 95% CI 0.147-0.99). CONCLUSIONS: Among internal medicine resident physicians, achievement of national physical activity guidelines appears to be inversely associated with burnout. Given the high national prevalence of burnout and inactivity, additional investigation of this relationship appears warranted.

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

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

Competency-based education and training in internal medicine.

Recent efforts to improve medical education include adopting a new framework based on 6 broad competencies defined by the Accreditation Council for Graduate Medical Education. In this article, the Alliance for Academic Internal Medicine Education Redesign Task Force II examines the advantages and challenges of a competency-based educational framework for medical residents. Efforts to refine specific competencies by developing detailed milestones are described, and examples of training program initiatives using a competency-based approach are presented. Meeting the challenges of a competency-based framework and supporting these educational innovations require a robust faculty development program. Challenges to competency-based education include teaching and evaluating the competencies related to practice-based learning and improvement and systems-based practice, as well as implementing a flexible time frame to achieve competencies. However, the Alliance for Academic Internal Medicine Education Redesign Task Force II does not favor reducing internal medicine training to less than 36 months as part of competency-based education. Rather, the 36-month time frame should allow for remediation to address deficiencies in achieving competencies and for diverse enrichment experiences in such areas as quality of care and practice improvement for residents who have demonstrated skills in all required competencies.

Use of an electronic medical record to profile the continuity clinic experiences of primary care residents.

PURPOSE: To assess the variation in outpatient educational experiences among residents in a primary care internal medicine residency program. METHOD: The authors conducted an observational study within a primary care residency program in Boston, Massachusetts, involving eight primary care residents in 2001-02. A data management system was created that uses information on clinical experiences collected from an electronic medical record (EMR). The EMR records clinical information from patient encounters in resident continuity clinics, including patient demographics and diagnostic codes entered by the residents. Primary and secondary diagnosis from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) were assigned to clinical categories (e.g., cardiology, orthopedics) and these assignments were programmed into a spreadsheet that could take the diagnostic data directly from the EMR downloads and produce reports using only the primary diagnosis, using all diagnoses, or using the assigned clinical categories. RESULTS: The EMR download showed 2,468 patient encounters for the eight residents in the primary care program. The most common clinical encounters were for health maintenance (17%), cardiology (14%), and women's health (10%). In contrast, rheumatology (0.5%) and hematology/oncology (2%) encounters were less frequent. There were substantial variations among residents in terms of distribution of encounter diagnoses, and the age and gender of patients seen in continuity clinic. CONCLUSIONS: Abstracting data from an EMR represents a feasible method for assessing programmatic and individual learner experiences in the outpatient setting. Such information may help target curricular adjustments to ensure an appropriate diversity and depth of clinical training.

Leaving the practice: effects of primary care physician departure on patient care.

BACKGROUND: Recent changes in the organization of health care services, coupled with rising rates of primary care physician (PCP) turnover, pose threats to the maintenance of a continuous patient-physician relationship. Little is known, however, about how PCP departure may affect patients' quality of health care. METHODS: Participants were adult patients whose PCPs left a large, multispecialty group practice from July 1, 1994, to June 30, 1996 (n = 3931), and adult patients of a set of matched PCPs who remained in the practice at least 2 years beyond the index PCPs departure dates (n = 8009). We compared the following measures of quality of care: adherence to recommended screening guidelines, adequacy of blood pressure and glycemic control in patients with hypertension and/or diabetes mellitus, and use of urgent care and emergency department services. RESULTS: Among the women who received a mammogram in the 2-year baseline period, a higher proportion of those whose PCP departed did not continue to receive mammograms, although the difference did not reach statistical significance (8.4% vs 5.1%; P =.08). For patients who had screening Papanicolaou smears or fecal occult blood testing during the baseline period, there was no significant difference between study and control groups in the likelihood that patients discontinued screening during the follow-up period (10.9% vs 10.7%; P =.93 and 28.8% vs 25.3%; P =.93, respectively). Similarly, diabetic patients of departed PCPs did not have higher risk of worsening glycemic control (31.7% vs 28.9%; P =.46); and hypertensive patients of departed PCPs actually had lower risks of worsening blood pressure control (16.5% vs 22.5%; P =.02). There was no difference in use of urgent care or emergency department services between patient groups. CONCLUSIONS: In this multispecialty group practice, patients of departed PCPs experienced little or no decrease in quality of care measures for routine screening, management of chronic disease, and use of urgent care and emergency department services.

Patient attitudes toward continuity of care.

BACKGROUND: Concern has been raised about managed care's effects on continuity of patient care, but little is known about how much value patients place on continuity. METHODS: We surveyed 2500 adult patients of a large New England health maintenance organization about their attitudes toward continuity and their willingness to spend additional time or money to maintain continuity with their primary care physician (PCP). RESULTS: Among the 1171 (46.8%) of patients responding, 460 (39.6%) of 1162 patients had had more than one PCP in the previous 5 years. Nearly all patients (1068 [91.5%] of 1167) rated continuity as very important or important; only 26 (2.2%) rated continuity as unimportant or very unimportant. However, only 256 (22.2%) of 1152 patients were willing to drive more than 60 minutes to maintain continuity with their PCP, and only 200 (18.2%) of 1096 would be willing to spend an additional $20 to $40 per month to maintain it. In multivariable analyses, patients were more willing to drive if they were nonwhite (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.4-3.6), older than 50 years (OR, 1.7; 95% CI, 1.2-2.4), or had less than a college education (OR, 1.6; 95% CI, 1.2-2.2). Patients who had been forced to change PCPs when their physician moved away were less willing to drive (OR, 0.5; 95% CI, 0.3-0.8) or spend more money (OR, 0.7; 95% CI, 0.5-1.0) to maintain continuity. CONCLUSIONS: Most patients in this sample indicated that continuity of care was important to them, but reported being unwilling to spend much additional personal time or money to maintain continuity with their current PCP. Nevertheless, an important subset of older and more vulnerable patients reported being more willing to pay to maintain continuity.