Factors Associated with Medical Students' Attitudes About Cost-Conscious Care: A Mixed-Methods Multi-school Study.

BACKGROUND: Because physician practices contribute to national healthcare expenditures, initiatives aimed at educating physicians about high-value cost-conscious care (HVCCC) are important. Prior studies suggest that the training environment influences physician attitudes and behaviors towards HVCCC. OBJECTIVE: To explore the relationship between medical student experiences and HVCCC attitudes. DESIGN: Quantitative and qualitative analysis of a multi-institutional survey. PARTICIPANTS: Medical students from nine US medical schools. APPROACH: A 44-item survey that included the Maastricht HVCCC Attitudes Questionnaire, a validated tool for assessing HVCCC attitudes, was administered electronically. Attitudinal domains of high-value care (HVC), cost incorporation (CI), and perceived drawbacks (PD) were compared using one-way ANOVA among students with a range of exposures. Open text responses inviting participants to reflect on their attitudes were analyzed using classical content analysis. KEY RESULTS: A total of 740 students completed the survey (response rate 15%). Students pursuing a "continuity-oriented" specialty held more favorable attitudes towards HVCCC than those pursuing "technique-oriented" specialties (HVC sub-score = 3.20 vs. 3.06; p = 0.005, CI sub-score = 2.83 vs. 2.74; p < 0.001). Qualitative analyses revealed personal, educational, and professional experiences shape students' HVCCC attitudes, with similar experiences interpreted differently leading to both more and less favorable attitudes. CONCLUSION: Students pursuing specialties with longitudinal patient contact may be more enthusiastic about practicing high-value care. Life experiences before and during medical school shape these attitudes, and complex interactions between these forces drive student perceptions of HVCCC.

An Analysis of Workplace-Based Assessments for Core Entrustable Professional Activities for Entering Residency: Does Type of Clinical Assessor Influence Level of Supervision Ratings?

PURPOSE: The authors describe use of the workplace-based assessment (WBA) coactivity scale according to entrustable professional activities (EPAs) and assessor type to examine how diverse assessors rate medical students using WBAs. METHOD: A WBA data collection system was launched at Oregon Health and Science University to visualize learner competency in various clinical settings to foster EPA assessment. WBA data from January 14 to June 18, 2021, for medical students (all years) were analyzed. The outcome variable was level of supervisor involvement in each EPA, and the independent variable was assessor type. RESULTS: A total of 7,809 WBAs were included. Most fourth-, third-, and second-year students were assessed by residents or fellows (755 [49.5%], 1,686 [48.5%], and 918 [49.9%], respectively) and first-year students by attending physicians (803 [83.0%]; P < .001). Attendings were least likely to use the highest rating of 4 (1 was available just in case; 2,148 [56.7%] vs 2,368 [67.7%] for residents; P < .001). Learners more commonly sought WBAs from attendings for EPA 2 (prioritize differential diagnosis), EPA 5 (document clinical encounter), EPA 6 (provide oral presentation), EPA 7 (form clinical questions and retrieve evidence-based medicine), and EPA 12 (perform general procedures of a physician). Residents and fellows were more likely to assess students on EPA 3 (recommend and interpret diagnostic and screening tests), EPA 4 (enter and discuss orders and prescriptions), EPA 8 (give and receive patient handover for transitions in care), EPA 9 (collaborate as member of interprofessional team), EPA 10 (recognize and manage patient in need of urgent care), and EPA 11 (obtain informed consent). CONCLUSIONS: Learners preferentially sought resident vs attending supervisors for different EPA assessments. Future research should investigate why learners seek different assessors more frequently for various EPAs and if assessor type variability in WBA levels holds true across institutions.

Contemporary Management and Outcomes of Veterans Hospitalized With Alcohol Withdrawal: A Multicenter Retrospective Cohort Study.

OBJECTIVES: Few studies describe contemporary alcohol withdrawal management in hospitalized settings or review current practices considering the guidelines by the American Society of Addiction Medicine (ASAM). METHODS: We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical or surgical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Demographic and comorbidity data were obtained from the Veteran Health Administration Corporate Data Warehouse. Inpatient management and hospital outcomes were obtained by chart review. Factors associated with treatment duration and complicated withdrawal were examined. RESULTS: Of the 594 patients included in this study, 51% were managed with symptom-triggered therapy alone, 26% with fixed dose plus symptom-triggered therapy, 10% with front loading regimens plus symptom-triggered therapy, and 3% with fixed dose alone. The most common medication given was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Symptom-triggered therapy alone (relative risk [RR], 0.68; 95% confidence interval [CI], 0.57-0.80) and front loading with symptom-triggered therapy (RR, 0.75; 95% CI, 0.62-0.92) were associated with reduced treatment duration. Lorazepam (RR, 1.20; 95% CI, 1.02-1.41) and phenobarbital (RR, 1.28; 95% CI, 1.06-1.54) were associated with increased treatment duration. Lorazepam (adjusted odds ratio, 4.30; 95% CI, 1.05-17.63) and phenobarbital (adjusted odds ratio, 6.51; 95% CI, 2.08-20.40) were also associated with complicated withdrawal. CONCLUSIONS: Overall, our results support guidelines by the ASAM to manage patients with long-acting benzodiazepines using symptom-triggered therapy. Health care systems that are using shorter acting benzodiazepines and fixed-dose regimens should consider updating alcohol withdrawal management pathways to follow ASAM recommendations.

Systems-Based Practice in Graduate Medical Education: Evolving Toward an Ideal Future State.

ABSTRACT: Systems-based practice (SBP) was first introduced as a core competency in graduate medical education (GME) in 2002 by the Accreditation Council for Graduate Medical Education as part of the Outcomes Project. While inclusion of SBP content in GME has become increasingly common, there have also been well-documented stumbling blocks, including perceptions that SBP has eroded the amount of curricular time available for more medically focused competencies, is not relevant for some practice contexts, and is not introduced early enough in training. As a result, SBP learning experiences often feel disconnected from medical trainees' practical reality. In this commentary, the authors provide guidance regarding potential changes that may facilitate the evolution of SBP toward an ideal future state where graduates bring a systems science mindset to all aspects of their work. Specific suggestions include the following: (1) expanding the SBP toolbox to reflect current-day health system needs, (2) evolve the teaching methodology, (3) broadening the scope of relevant SBP content areas, and (4) emphasizing SBP as an integrated responsibility for all health care team members. Levers to enact this transformation exist and must be used to influence change at the learner, faculty, program, and clinical learning environment levels.Physicians operate within an increasingly complex health care system that highlights the intersection of health care with complex social, environmental, and relational contexts. Consequently, the role of SBP in both physician work responsibilities and educational requirements continues to expand. To meet this growing demand, GME must adapt how it supports and trains the next generation of systems thinkers, ensuring they understand how levers in the health care system directly affect health outcomes for their patients, and integrate SBP into the foundation of GME curricula in an inclusive, holistic, and unrestrained way.

A Multicenter Observational Study Comparing Virtual with In-Person Morning Reports during the COVID-19 Pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic disrupted how educational conferences were delivered, leaving programs to choose between in-person and virtual morning report formats. The objective of our study was to describe morning reports during the COVID-19 pandemic, including the use of virtual formats, attendance, leadership, and content. METHODS: A prospective observational study of morning reports was conducted at 13 Internal Medicine residency programs between September 1, 2020 and March 30, 2021, including a follow-up survey of current morning report format in January 2023. RESULTS: In total, 257 reports were observed; 74% used virtual formats, including single hospital, multiple hospital, and a hybrid format with both in-person and virtual participants. Compared with in-person reports, virtual reports had more participants, with increased numbers of learners (median 21 vs 7; P < 0.001) and attendings (median 4 vs 2; P < 0.001), and they were more likely to involve medical students (83% vs 40%; P < 0.001), interns (99% vs 53%; P < 0.001), and program directors (68% vs 32%; P < 0.001). Attendings were less likely to lead virtual reports (3% vs 28%, P < 0.001). Virtual reports also were more likely to be case based (88% vs 69%; P < 0.001) and to use digital presentation slides (91% vs 36%; P < 0.001). There was a marked increase in the number of slides (median 20 vs 0; P < 0.001). As of January 2023, all 13 programs had returned to in-person reports, with only 1 program offering an option to participate virtually. CONCLUSIONS: During the COVID-19 pandemic, virtual morning report formats predominated. Compared with traditional in-person reports, virtual report increased attendance, favored resident leadership, and approached a similar range of patient diagnoses with a greater number of case-based presentations and slides. In spite of these characteristics, all programs returned to an in-person format for morning report as pandemic restrictions waned.

What internal medicine attendings talk about at morning report: a multicenter study.

BACKGROUND: Morning report is a core educational activity in internal medicine resident education. Attending physicians regularly participate in morning report and influence the learning environment, though no previous study has described the contribution of attending physicians to this conference. This study aims to describe attending comments at internal medicine morning reports. METHODS: We conducted a prospective, observational study of morning reports conducted at 13 internal medicine residency programs between September 1, 2020, and March 30, 2021. Each attending comment was described including its duration, whether the comment was teaching or non-teaching, teaching topic, and field of practice of the commenter. We also recorded morning report-related variables including number of learners, report format, program director participation, and whether report was scripted (facilitator has advance knowledge of the case). A regression model was developed to describe variables associated with the number of attending comments per report. RESULTS: There were 2,344 attending comments during 250 conferences. The median number of attendings present was 3 (IQR, 2-5). The number of comments per report ranged across different sites from 3.9 to 16.8 with a mean of 9.4 comments/report (SD, 7.4). 66% of comments were shorter than one minute in duration and 73% were categorized as teaching by observers. The most common subjects of teaching comments were differential diagnosis, management, and testing. Report duration, number of general internists, unscripted reports, and in-person format were associated with significantly increased number of attending comments. CONCLUSIONS: Attending comments in morning report were generally brief, focused on clinical teaching, and covered a wide range of topics. There were substantial differences between programs in terms of the number of comments and their duration which likely affects the local learning environment. Morning report stakeholders that are interested in increasing attending involvement in morning report should consider employing in-person and unscripted reports. Additional studies are needed to explore best practice models of attending participation in morning report.

Adapting SQUIRE 2.0 to Create a Quality Improvement Evidence-Based Medicine Critical Appraisal Tool (QI-EBM-CAT) for Graduate Medical Education Trainees.

Background: Evidence-based medicine (EBM) has long been taught to physician trainees for critical appraisal of research manuscripts. There is no parallel or similar framework to guide trainees in the appraisal of quality improvement (QI) literature. Objective: To adapt existing guidelines of QI manuscript reporting into an educational QI-EBM appraisal tool to help residents distinguish research and QI manuscripts, assess QI designs and methodologies, and evaluate QI manuscripts' strengths and weaknesses. Methods: Between 2018 and 2021, we developed a QI-EBM critical appraisal tool (QI-EBM-CAT) and performed 3 plan-do-study-act cycles to refine the tool based on JAMA and SQUIRE 2.0 guidelines. We then surveyed residents regarding the usefulness of the tool and their confidence in evaluating QI manuscripts before and after completing a QI-EBM workshop using the QI appraisal tool. Results: Sixty-six of 74 internal medicine postgraduate year (PGY)-1 to PGY-3 residents (89.2%) completed the workshop and assessment surveys in 2021. The workshop was found to be moderately to very useful by 85.1% (63 of 74) of residents as a framework for QI manuscript critical analysis. The summary confidence score in QI manuscript critical appraisal improved from a 64% rating of moderately to very confident in the pre-period to 94.6% in the post-period (P<.001) with statistical improvements in all 5 confidence areas assessed (P<.001). Conclusions: The QI-EBM-CAT, designed to teach residents how to critically assess QI manuscripts using EBM principles, resulted in subjective improvements in confidence of QI manuscript analysis.

Simulating for Quality: A Centralized Quality Improvement and Patient Safety Simulation Curriculum for Residents and Fellows.

PROBLEM: Requirements for experiential education in quality improvement and patient safety (QI/PS) in graduate medical education (GME) have recently expanded. Major challenges to meeting these requirements include a lack of faculty with the needed expertise, paucity of standardized curricular models allowing for skill demonstration, and inconsistent access to data for iterative improvement. APPROACH: In October 2017, the authors began development of a centralized QI/PS flipped-classroom simulation-based medical education (SBME) curriculum for GME trainees across multiple disciplines at Oregon Health & Science University (OHSU). The curriculum development team included OHSU and Veterans Affairs faculty with experience in QI/PS and SBME, as well as house officers. The curriculum consisted of a preassessment and prework readings and videos (sent 3 weeks before the simulation day) and an 8-hour simulation day, with introductory activities, 4 linked simulation sessions, and concluding activities. The 4 linked sessions followed the same medication error from disclosure and reporting to root cause analysis, iterative implementation of an action plan, and consolidation of lessons learned into routine operations with Lean huddles. OUTCOMES: In academic year 2018-2019, 71 residents and fellows of various postgraduate years from 23 training programs enrolled in 2 pilot sessions. Learners reacted favorably to the simulation curriculum. Learner attitudes, confidence, knowledge, and skills significantly increased across all QI/PS domains studied. NEXT STEPS: This approach focuses a small cadre of educators toward the creation of a centralized resource that, owing to its experiential SBME foundation, can accommodate many learners with data-driven practice-based learning and improvement cycles in a shorter time frame than traditional QI initiatives. Next steps include the addition of a control group, assessment of the sustainability of learner outcomes, translation of learning to behavior change and improvements in patient and health system outcomes, and adapting the materials to include learners from different professions and levels.

Theory in quality improvement and patient safety education: A scoping review.

INTRODUCTION: Theory plays an important role in education programming and research. However, its use in quality improvement and patient safety education has yet to be fully characterized. The authors undertook a scoping review to examine the use of theory in quality improvement and patient safety education. METHODS: Eligible articles used theory to inform the design or study of a quality improvement or patient safety curriculum. The authors followed scoping review methodology and searched articles referenced in 20 systematic reviews of quality improvement and patient safety education, or articles citing one of these reviews, and hand searched eligible article references. Data analysis involved descriptive and interpretive summaries of theories used and the perspectives the theories offered. RESULTS: Eligibility criteria were met by 28 articles, and 102 articles made superficial mention of theory. Eligible articles varied in professional group, learning stage and journal type. Theories fell into two broad categories: learning theories (n = 20) and social science theories (n = 11). Theory was used in the design (n = 12) or study (n = 17) of quality improvement and patient safety education. The range of theories shows the opportunity afforded by using more than one type of theory. DISCUSSION: Theory can guide decisions regarding quality improvement and patient safety education practices or play a role in selecting a methodology or lens through which to study educational processes and outcomes. Educators and researchers should make deliberate choices around the use of theory that relates to aspects of an educational program that they seek to illuminate.

The Mystery Dinner RCA: Using Gamification and Simulation to Teach Root Cause Analysis.

Introduction: Root cause analysis (RCA) is a widely utilized tool for investigating systems issues that lead to patient safety events and near misses, yet only 38% of learners participate in an interdisciplinary patient safety investigation during training. Common barriers to RCA education and participation include faculty time and materials, trainee time constraints, and learner engagement. Methods: We developed a simulated RCA workshop to be taught to a mix of medical and surgical specialties from over 11 GME programs and to third-year medical students. The workshop was a single 90-minute session formatted as a gamified mystery dinner including characters and sequentially revealed clues to promote engagement. Participant satisfaction and subjective knowledge, skills, and attitudes were assessed with a pre/post survey. Results: The workshop was completed by 134 learners between October 2018 and October 2019. The short workshop duration and premade simulation allowed a small number of faculty to train a wide variety of learners in various educational settings. Participants' presurvey (124 out of 134, 92%) versus postsurvey (113 out of 134, 84%) responses showed that attitudes about RCA were statistically improved across all domains queried, with an average effect size of 0.6 (moderate effect); 91% of participants would recommend this course to a colleague. Discussion: A 90-minute, gamified, simulated RCA workshop was taught to medical students and multiple GME specialties with subjective improvements in patient safety attitudes and knowledge while alleviating faculty time constraints in case development.

Implementing a Real-time Workplace-based Assessment Data Collection System Across an Entire Medical School's Clinical Learning Environment.

This article was migrated. The article was marked as recommended. Background & Objectives: Workplace-based assessments (WBAs) are a vital aspect of medical student competency assessment for the core Entrustable Professional Activities (EPAs), but pose significant challenges since assessment must occur in real-time during the routine care of patients. We developed an online WBA system designed to overcome these challenges, and implemented it across an entire undergraduate medical education program to address the need for EPA competency assessment. We describe the development and implementation process, and present initial results from our inaugural medical student cohort. Methods: The WBA tool was designed to be student-driven, easy to use, and minimally disruptive to clinical care. Students trigger assessments by choosing the desired EPA to be assessed within a custom-built Qualtrics XM survey application. Their clinical assessor is prompted to select their level of involvement in the activity using the modified Ottawa co-activity scale and provide brief written feedback. Direct verbal feedback at time of discussion is encouraged. Results: 3,568 WBAs were completed. The mean number of assessments per student for all EPAs combined was 24.27 with a range of 1-103. All students completed at least one WBA. Over the course of 12 months, the mean number of EPAs recorded per student in this cohort was lowest for EPA 10 (Recognizing a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management) (mean=0.36; range 0-4; n=53) and was highest for EPA 6 (Provide an Oral Presentation for a Clinical Encounter) (mean=5.46; range 1-17; n=803). The mean number of minutes it took to complete the assessments was 2.7 minutes with a standard deviation of 1.2 minutes (n=2,803). Conclusion: An electronic application-based survey collecting real-time WBAs to assess progress toward attaining competence in EPA performance resulted in increased assessment data within a medical school cohort.

Patient vs provider perspectives of 30-day hospital readmissions.

Objective: To compare patients' and providers' views on contributors to 30-day hospital readmissions. Design: Analysis of a qualitative interview survey between 18 May-30 June 2015. Setting: Interviews were conducted during the 30-day readmission hospitalisation at a single tertiary care academic hospital. Participants: We conducted 178 interviews of readmitted patients. Measures: We queried opinions of what factors patients believed contributed to their rehospitalisation and compared this with the perspective of the index admission provider. The primary outcome was the view that the readmission was preventable. A review by a RN (nurse) case manager also provided an assessment based on patient report, provider report and chart review. Results: Patients were more likely to view a readmission as preventable compared with physicians (p<0.0001). Patients identified system issues (defined as factors controlled by the hospital discharge process) as contributors to their readmission in 58% (103/178) of cases while providers identified system issues as the contributor to a patients' readmission in 2% (2/101) of cases. Patients with poor functional status were more likely to feel the cause of their readmission was due to system issues than patients with better functional status (p=0.03). A RN case manager review determined that in 48% (86/178) of cases the system had some amount of contribution to a patient's readmission. There was no significant difference in belief that the readmission was preventable between the RN case manager and the patient (p=0.47). Conclusions: Readmitted patients often feel that the hospital system contributed to their readmission. Providers did not recognise patient and RN case manager identified issues as contributors to hospital readmissions.

A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback.

PURPOSE: Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns. DESIGN: Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments. RESULTS: The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001). CONCLUSIONS: We successfully implemented a novel high value care curriculum that specifically targets intern physicians.

A resident-created hospitalist curriculum for internal medicine housestaff.

The growth of hospital medicine has led to new challenges, and recent graduates may feel unprepared to meet the expanding clinical duties expected of hospitalists. At our institution, we created a resident-inspired hospitalist curriculum to address the training needs for the next generation of hospitalists. Our program provided 3 tiers of training: (1) clinical excellence through improved training in underemphasized areas of hospital medicine, (2) academic development through required research, quality improvement, and medical student teaching, and (3) career mentorship. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents. Journal of Hospital Medicine 2016;11:646-649. © 2016 Society of Hospital Medicine.