Resident Assessment of Clinician Educators According to Core ACGME Competencies.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires faculty to pursue annual development to enhance their teaching skills. Few studies exist on how to identify and improve the quality of teaching provided by faculty educators. Understanding the correlation between numeric scores assigned to faculty educators and their tangible, practical teaching skills would be beneficial. OBJECTIVE: This study aimed to identify and describe qualities that differentiate numerically highly rated and low-rated physician educators. DESIGN: This observational mixed-methods study evaluated attending physician educators between July 1, 2015, and June 30, 2021. Quantitative analysis involved descriptive statistics, normalization of scores, and stratification of faculty into tertiles based on a summary score. We compared the highest and lowest tertiles during qualitative analyses of residents' comments. PARTICIPANTS: Twenty-five attending physicians and 111 residents in an internal medicine residency program. MAIN MEASURES: Resident evaluations of faculty educators, including 724 individual assessments of faculty educators on 15 variables related to the ACGME core competencies. KEY RESULTS: Quantitative analyses revealed variation in attending physician educators' performance across the ACGME core competencies. The highest-rated teaching qualities were interpersonal and communication skills, medical knowledge, and professionalism, while the lowest-rated teaching quality was systems-based practice. Qualitative analyses identified themes distinguishing high-quality from low-quality attending physician educators, such as balancing autonomy and supervision, role modeling, engagement, availability, compassion, and excellent teaching. CONCLUSIONS: This study provides insights into areas where attending physicians' educational strategies can be improved, emphasizing the importance of role modeling and effective communication. Ongoing efforts are needed to enhance the quality of faculty educators and resident education in internal medicine residency programs.

Rallying All Resources: A Multidisciplinary Innovation to Plan for the Projected COVID-19 Inpatient Surge.

BACKGROUND: The COVID-19 pandemic resulted in the need for hospitals to plan for a potential "surge" of COVID-19 patients. PROBLEM: Prior to the onset of the COVID-19 pandemic, our hospital adult acute care capacity ranged 90% to 100%, and a potential hospital surge was projected for Oregon that would exceed existing capacity. APPROACH: A multidisciplinary team with stakeholders from nursing leadership, nursing units, nurse-led case management, and physicians from hospital medicine was convened to explore the conversion of an ambulatory surgical center to overflow patient acute care capacity. OUTCOMES: A protocol was rapidly created and implemented, ultimately transferring 12 patients to an ambulatory surgery unit. CONCLUSIONS: This project highlighted the ability for stakeholders and innovators to work together in an interprofessional, multidisciplinary way to rapidly create an overflow unit. While this innovation was designed to address COVID-19, the lessons learned can be applied to any other emerging infectious disease or acute care capacity crisis.

Transitioning From Volume to Value: Lessons Learned From the Dissolution of a Population Health Partnership.

In 2017, the authors published an article describing the experiences of Oregon Health & Science University (OHSU) as it adapted to new challenges of changing payment models, the imperative to manage the health of populations, and the desire to compete for statewide contracts. The authors described Propel Health, a multi-institution partnership created in 2013 to deliver the tools, methods, and support necessary for population health management. In the ensuing two years there were considerable changes to the structure and mission of Propel Health, ultimately resulting in its dissolution in January 2018. Using the organizational framework from the original publication, this article shares a number of lessons learned with other academic medical centers as they make the journey toward value-based care and population health management. Examples of lessons learned include ensuring that clinical and administrative leadership are aligned and that shared partnership goals are not eclipsed by local strategic needs. The potential for shared data remains a powerful motivation to partner; however, technology integration can be costly and complex. Once data are available, the ability to respond quickly is a key competency. Understanding individual sites' needs and capabilities is critical before embarking on shared clinical programs. Best practices from industry-specific experts should be employed. Lastly, it is essential for partners to determine how shared gains/losses will be attributed, and how aggressively risk should be required. Next steps for OHSU, including new, local partnerships, are shared.

Transitioning From Volume to Value: One Academic Medical Center's Approach to Improving Population Health.

PROBLEM: The U.S. health care system is undergoing a major transformation. Clinical delivery systems are now being paid according to the value of the care they provide, in accordance with the Triple Aim, which incorporates improving the quality and cost of care and the patient experience. Increasingly, financial risk is being transferred from insurers to clinical delivery systems that become responsible for both episode-based clinical care and the longitudinal care of patients. Thus, these delivery systems need to develop strategies to manage the health of populations. Academic medical centers (AMCs) serve a unique role in many markets yet may be ill prepared for this transformation. APPROACH: In 2013, Oregon Health & Science University (OHSU) partnered with a large health insurer and six other hospitals across the state to form Propel Health, a collaborative partnership designed to deliver the tools, methods, and support necessary for population health management. OHSU also developed new internal structures and transformed its business model to embrace this value-based care model. OUTCOMES: Each Propel Health partner included the employees and dependents enrolled in its employee medical plan, for approximately 55,000 covered individuals initially. By 2017, Propel Health is expected to cover 110,000 individuals. Other outcomes to measure in the future include the quality and cost of care provided under this partnership. NEXT STEPS: Anticipated challenges to overcome include insufficient primary care networks, conflicting incentives, local competition, and the magnitude of the transformation. Still, the time is right for AMCs to commit to improving the health of populations.

A multidisciplinary initiative to standardize intensive care to acute care transitions.

QUALITY ISSUE: Transfers from intensive care units to acute care units represent a complex care transition for hospitalized patients. Within our institution, variation in transfer practices resulted in unpredictable processes in which patient safety concerns were raised. INITIAL ASSESSMENT: Key stakeholders were engaged across the institution. Patient safety ('incident') reports and a staff survey identified safety concerns. CHOICE OF A SOLUTION: Using lean methodology, current transfer processes were mapped for the four adult intensive care units and waste was identified. During a summit of key stakeholders an ideal transfer process was conceived and a structured handoff tool (checklist) was developed. A daily management system (DMS) was implemented to monitor adherence. EVALUATION: The primary process outcome was adherence to the standardized workflow. Audits at 4, 8, and 12 months after implementation indicated that the checklist was used for 100% of transfers. Secondary outcomes included the percentage of transfers completed within a pre-specified time window of 120 minutes, provider notification of patient arrival on the acute care unit, and staff survey responses assessing adequacy of transfer communication. LESSONS LEARNED: Prior work has shown that structuring handoffs can improve patient safety, but the novelty of this project was addressing the transfer process in its entirety, across silos of care. Factors leading to the success of this project were the involvement of key stakeholders across the entire institution early in the project development phase, employment of lean methodology, and implementation of tools to guide workflow adherence and track causes of deviation from the workflow.

Putting the pieces together: necrolytic migratory erythema and the glucagonoma syndrome.

Glucagonomas are slow-growing, rare pancreatic neuroendocrine tumors. They may present with paraneoplastic phenomena known together as the "glucagonoma syndrome." A hallmark sign of this syndrome is a rash known as necrolytic migratory erythema (NME). In this paper, the authors describe a patient with NME and other features of the glucagonoma syndrome. The diagnosis of this rare tumor requires an elevated serum glucagon level and imaging confirming a pancreatic tumor. Surgical and medical treatment options are reviewed. When detected early, a glucagonoma is surgically curable. It is therefore imperative that clinicians recognize the glucagonoma syndrome in order to make an accurate diagnosis and refer for treatment.

Thoracic endometriosis unmasked by ovarian hyperstimulation for in vitro fertilization.

Thoracic endometriosis syndrome is a well-described, rare manifestation of endometriosis. We present a case of a 35-year old woman undergoing controlled ovarian stimulation prior to in vitro fertilization (IVF) who developed bilateral hemorrhagic pleural effusions. She was initially diagnosed with ovarian hyperstimulation syndrome, a complication of infertility therapy; however, she was later found to have occult thoracic endometriosis. We describe ovarian hyperstimulation syndrome and review the manifestations of thoracic endometriosis syndrome. Although endometriosis is a hormone-dependent disease, the rate of IVF complications related to endometriosis is low.

Fulminant, non-antibiotic associated Clostridium difficile colitis following Salmonella gastroenteritis.

In the last decade there has been increasing awareness of the virulence and changing epidemiology of Clostridium difficile (C. difficile). While the vast majority of clinical cases of C. difficile are associated with antimicrobial or nosocomial exposure, this syndrome has been well described in the absence of antibiotic use. We present an unusual case of fatal, non-antibiotic associated C. difficile colitis following Salmonella serotype Saintpaul gastroenteritis in a previously healthy young person. We review the typical risk factors for C. difficile colitis and fulminant disease. We also review the epidemiology of community-acquired C. difficile-associated disease (CA-CDAD) and highlight Salmonella infection as a potential risk factor for development of CA-CDAD.

Principles of effective consultation: an update for the 21st-century consultant.

BACKGROUND: Little information in the literature exists to guide consult interactions between different medical specialties. METHODS: A total of 323 general internists, family medicine physicians, general surgeons, orthopedic surgeons, and obstetricians/gynecologists (OB/GYNs) from 3 academic medical centers completed a survey addressing their ideal relationship with consultants. Differences between surgeons and nonsurgeons were calculated using logistic regression, adjusting for location and trainee status. Differences between different specialties of surgeons were calculated using analysis of variance with Scheffe post hoc analysis RESULTS: There was a 72% response rate. About half of respondents were surgeons and the rest were general internists and family medicine physicians. More nonsurgeons (69%) desired the consultant to focus on a narrow question than did surgeons (41%). Over half (59%) of family medicine physicians and internists preferred to retain order-writing authority on their patients compared with 37% of surgeons (P<.001). Of the surgeons preferring to retain authority, 70% believed it was appropriate for consultants to write orders after a verbal discussion. Orthopedic surgeons desired consultants to write orders and co-manage patients significantly more compared with general surgeons and OB/GYNs (P<.001). Only 29% of physicians thought literature references were useful in consultations. Most physicians (75%) desired direct verbal communication with the specialist providing the consultation. Most family physicians (78%) believed there was little need for general internal medicine input, preferring to consult medicine subspecialists directly. CONCLUSIONS: Specialty-dependent differences exist in consult preferences of physicians. These differences vary from the extremes of orthopedic surgeons desiring a comprehensive co-management approach with the consultant to general internists and family medicine physicians desiring to retain control over order writing and have a more focused consultant approach.