The Snowstorm.

In this narrative medicine essay, a family physician takes a moment-by-moment, one-step-at-a-time approach to move from her couch to recovery from treatment for lymphoblastic leukemia to finally reaching the cross-country ski trails.

Teaching Self-directed Learning Skills Through a Resident-Led Milestones Process.

Introduction: The Accreditation Council for Graduate Medical Education allows flexibility for resident roles in the Milestone assessment process. The University of Utah Family Medicine Residency implemented a resident-led Milestones process to cultivate the skill of self-assessment and promote resident ownership of their learning. Methods: Residents were provided comprehensive evaluation data and asked to self-assess their competency on each Milestone, with input from their advisor. Residents presented their self-assessment to the Clinical Competency Committee, who then determined the final score for each Milestone. A 10-question survey examined perceptions of the resident-led Milestones process by residents and faculty. We calculated means and standard deviations (SD). Results: A total of 16 of 24 residents (67% response rate) and 12 of 14 faculty (86% response rate) completed the survey. Residents agreed most highly with the following statements: "I have good support from my advisor in being prepared to lead my Milestones meeting," "I am actively engaged in guiding the development of my own Milestones ratings," and "Leading my Milestones meeting assists me in accurately self-assessing my progress." Residents showed high agreement that "My final Milestones scores accurately reflect my behavior and level of knowledge." Residents rated the stress as low, in response to the statement, "My Milestones meeting is stressful for me." Faculty responses were similar but tended toward lower scores than residents. Conclusion: The resident-led Milestones process engages residents actively in self-assessment. Residents and faculty believe the process provides accurate assessment results without undue stress; this process potentially increases residents' ability to understand their own learning needs and direct their own learning process.

Implementing an Anonymous Closed-Loop Feedback Process and Associations With ACGME Annual Survey Scores in a Family Medicine Residency.

BACKGROUND AND OBJECTIVES: The annual Accreditation Council for Graduate Medical Education (ACGME) survey evaluates numerous variables, including resident satisfaction with the training program. We postulated that an anonymous system allowing residents to regularly express and discuss concerns would result in higher ACGME survey scores in areas pertaining to program satisfaction. METHODS: One family medicine residency program implemented a process of quarterly anonymous closed-loop resident feedback and discussion in academic year 2012-2013. Data were tracked longitudinally from the 2011-2019 annual ACGME resident surveys, using academic year 2011-2012 as a baseline control. RESULTS: For the survey item "Satisfied that evaluations of program are confidential," years 2013-2014, 2014-2015, and 2018-2019 showed a significantly higher change from baseline. For "Satisfied that program uses evaluations to improve," year 2018-2019 had a significantly higher percentage change from baseline. For "Satisfied with process to deal with problems and concerns," year 2018-2019 showed significantly higher change. For "Residents can raise concerns without fear," years 2013-2014 and 2018-2019 saw significantly higher changes. CONCLUSIONS: These results suggest that this feedback process is perceived by residents as both confidential and promoting a culture of safety in providing feedback. Smaller changes were seen in residents' belief that the program uses evaluations to improve, and in satisfaction with the process to deal with problems and concerns.

Use of a Feedback Survey as a Part of a Wellness Champions Program to Improve Academic Faculty Satisfaction and Burnout: Implications for Burnout in Academic Health Centers.

BACKGROUND: Faculty and trainee well-being at academic medical centers is a nationwide concern. In response, the University of Utah Health created a system-wide provider wellness program that used individual faculty champions who were empowered to 1) examine the unique needs of their department or division using a lens of quality improvement, 2) design projects to address well-being, and 3) measure impact of projects addressing well-being. One team used a feedback tool to attempt to improve the well-being of Family Medicine faculty by better understanding challenges and developing a roadmap for action. OBJECTIVE: Evaluate the effectiveness of an anonymous feedback tool on faculty well-being. METHODS: The Division of Family Medicine developed and implemented a quarterly anonymous faculty survey to facilitate an ongoing improvement process for faculty wellness in 2016. The faculty survey identified thematic concerns, which were used to develop constructive solutions and systemic changes. RESULTS: A closed loop feedback structure provided rich faculty input into impacts on burnout and professional well-being. Sense of control (good to optimal) over workload among faculty increased significantly (p = 0.011) from 10% to 42% over one year exhibiting a large effect size (Cohen's h = 0.751). Faculty burnout, using a single item emotional exhaustion question validated to the Maslach Burnout Inventory, was reduced from 48% to 25% showing a medium effect size (Cohen's h = 0.490 with p = 0.097). Work related stress was reduced from 72% to 50% demonstrating clinical significance (Cohen's h = 0.465) but not statistical significance (p = 0.154)-an effect which was more noticeable when comparing means between years (Cohen's d=0.451with p = 0.068). Response rate was 100% in 2016 (29/29) and 92% (23/25) in 2017. CONCLUSION: This faculty survey, which has since been adopted by other groups at the University of Utah, could help improve well-being in a variety of health care professions.

A Longitudinal Curriculum for Quality Improvement, Leadership Experience, and Scholarship in a Family Medicine Residency Program.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) requires all residents be trained in quality improvement (QI), and that they produce scholarly projects. While not an ACGME requirement, residents need leadership skills to apply QI knowledge. We developed the Skills-based Experiential Embedded Quality Improvement (SEE-QI) curriculum to integrate training in QI, leadership, and scholarship. METHODS: The University of Utah Family Medicine Residency Program began using the novel curriculum in 2012. The aim of the curriculum is to tie didactic teaching in quality improvement, leadership, and scholarship with skills application on multidisciplinary QI teams. Coaching for resident leaders is provided by faculty. Third-year resident leaders prepare academic presentations. Results of the ACGME Practice-Based Learning and Improvement (PBLI) 3 scores and number of scholarship presentations are described as a measure of efficacy. RESULTS: Two cohorts of residents completed the curriculum and all competency assessments. The average initial and final competency scores for competency PBLI-3 showed improvement and the average final competency for each cohort was above the proficient level. The residency requirements for QI scholarship did not change with introduction of the curriculum, but the amount of optional curricular QI scholarship and independent QI scholarship increased. CONCLUSIONS: The SEE-QI curriculum resulted in a high level of resident QI competency, opportunity for leadership training, and an increase in scholarship. We studied the results of this curriculum at one institution. Efforts to tie QI, leadership, and scholarship training should be evaluated at other programs.

Increasing Chlamydia Testing Rates via Targeted Outreach.

BACKGROUND AND OBJECTIVES: Chlamydia trachomatis is the most prevalent bacterial sexually transmitted infection (STI) in the United States. Annual chlamydia screening of asymptomatic, sexually active women age 16 to 24 years and in older women who are at increased risk for infection is recommended. This study built on prior work in which our university-based family medicine clinic implemented quality improvement (QI) interventions in 2016 and 2017 to increase our chlamydia screening rate. Our primary aim in the current study was to increase the screening rate by 10%. Our secondary aim was to determine the number of patient contacts that yielded maximum test rates. METHODS: For the most recent QI cycle, we conducted a prospective cohort study from December 2017 through March 2018. Using the FOCUS-PDSA model, a resident-led, interdisciplinary QI team developed the aims and implemented an intervention to streamline patient outreach. We also retrospectively analyzed data from the previous QI cycle to determine the number of tests obtained after each patient contact. RESULTS: Chlamydia testing increased from 54% to 56.3% between December 2017 and March 2018. The majority of tests were completed by four patient contacts; additional contacts yielded few additional tests. CONCLUSIONS: Persistent outreach increases chlamydia screening rates. This QI project could be replicated in other clinical settings to improve the screening of chlamydia or other diseases.

Creation of a family medicine residency blog.

Objective To describe the process of creating the Family Medicine Vital Signs blog, curated and edited by residents and faculty at the University of Utah Family Medicine Residency Program and to obtain feedback from participants regarding educational impact. Methods Each resident and faculty member contributes at least one blog post per year (with other invited authors), resulting in one post per week on the blog site. An editorial board composed of residents and faculty provides direction and editorial assistance for each post. Residency staff assist in providing authors with reminders and logistical support. A survey was conducted of blog contributors to understand their perceptions of the blog's educational value. Results The Family Medicine Vital Signs blog was started in July 2014, with 40% (n = 68) of the 170 posts provided by residents, 38.2% (n = 65) by faculty, and 21.8% (n = 37) by invited authors through June 2017. It has averaged nearly 100 unique readers per week and has had 15 posts republished in different venues. The participant survey demonstrated scores above the median-possible score, showing positive impact in support of the educational goals. Conclusion A residency blog provides a venue for educational instruction, supporting physician development of communication skills, community engagement, and advocacy.

Development and Validation of the Foundational Healthcare Leadership Self-assessment.

BACKGROUND AND OBJECTIVES: We sought to develop and validate a self-assessment of foundational leadership skills for early-career physicians. METHODS: We developed a leadership self-assessment from a compilation of materials on health care leadership skills. A sequential exploratory study was conducted using qualitative and quantitative analysis for face, content, and construct validity of the self-assessment. First, two focus groups were conducted with leaders in medicine and family medicine residents, to refine the pilot self-assessment. The self-assessment pilot was then tested with family medicine residents across the country, and the results were quantitatively evaluated with principal component analysis. This data was used to reduce and group the statements into leadership domains for the final self-assessment. RESULTS: Twenty-two invited family medicine residency programs agreed to distribute the survey. A total of 163 family medicine residents completed the survey, representing 16 to 20 residency programs from 12 states (response rate 28.9% to 34.8%). Analysis showed important differences by residency year, with more advanced residents scoring higher. The analysis reduced the number of items from 33 on the pilot assessment to 21 on the final assessment, which the authors titled the Foundational Healthcare Leadership Self-assessment (FHLS). The 21 items were grouped into five leadership domains: accountability, collaboration, communication, team management, and self-management. CONCLUSIONS: The FHLS is a validated 21-item self-assessment of foundational leadership skills for early career physicians. It takes less than 5 minutes to complete, and quantifies skill within five domains of foundational leadership. The FHLS is a first step in developing educational and evaluative assessments for training medical residents as clinician leaders.

Establishing a Culture of Intentional Wellness: Lessons From a Family Medicine Resident Focus Group.

INTRODUCTION: Residency training is a peak time of physician distress, but also a venue in which residents can learn skills to thrive in a high-risk career. The goal of this study was to examine residents' perceptions of the value of teaching wellness as an integrated component of a residency program. METHODS: Researchers at the University of Utah Family Medicine Residency Program conducted a focus group with graduating family medicine residents regarding their perception of wellness and wellness skills, after having completed an intentional wellness curriculum integrated through their 3 years of residency. We used open coding to identify themes of the residents' perceptions of the wellness curriculum. RESULTS: Four interconnected themes emerged: (1) describing the relevance of wellness to a medical career; (2) the wellness curriculum as prioritized and intentional; 3) The value of wellness skills learned through the curriculum; and (3) the role of community ethos in maintaining wellness. CONCLUSIONS: Residents consider wellness to be a critical facet of being an effective physician. Our results suggest that a culture of wellness can be created through deliberate and transparent curricular design, helping residents to view wellness as a priority.

Residency redesign to accommodate trends in geriatrics: an RC-FM variance to establish a patient-centered medical home in an assisted living facility.

BACKGROUND AND OBJECTIVES: Family physicians are poised to provide medical care to older adults residing in the broad range of facilities now currently available to this population. To date, geriatric training has focused on skilled nursing facilities, particularly for the required Review Committee for Family Medicine (RC-FM) longitudinal experience. This article describes the development and evaluation of an RC-FM approved assisted living curricular variance to the current nursing home longitudinal experience with emphasis on the principles of the Patient-centered Medical Home (PCMH) model and an interprofessional team concept. METHODS: Second- and third-year family medicine residents were assigned as the primary care providers for two continuity patients in an assisted living facility. Patients were seen bimonthly within the construct of an interprofessional geriatric team. During the 2-year curricular variance, assessment of residents' skills, knowledge, and attitudes of the residents was conducted before and after the experience through direct skills observations, written testing, and focus groups. RESULTS: Of 18 geriatric competencies evaluated by direct observation, there was statistically significant improvement in seven areas. The composite score for these competencies was statistically significant. The attitudinal scores were initially high and remained high throughout the 2-year period. Knowledge testing was not significantly different before or after the experience. CONCLUSIONS: The assisted living facility is a viable clinical educational setting to develop geriatric competencies within a PCMH model. Providing geriatric clinical opportunities across the continuum of care can better prepare family medicine residents for future practice.

Health-related concerns of the female athlete: a lifespan approach.

Exercise is beneficial for women of all ages and is associated with long-term health benefits and enhanced well-being. Nevertheless, active women and girls are at risk for conditions resulting from sports and exercise participation. Because of their unique physiology, children are more susceptible to heat illness than adolescents and younger adults. Childhood sports injuries tend to involve the growth plate. Adolescents share some concerns with child athletes but have injuries more similar to those that occur in adults, especially ligament and tendon injuries. Adolescents and adult women are at risk for anterior cruciate ligament injuries, patellofemoral pain syndrome, and stress fractures. For athletes in these age groups, physicians should screen for pelvic floor dysfunction and the female athlete triad, especially in patients with a history of stress fractures. In adult women, exercise can contribute to disease prevention and management. Continuation of an appropriate exercise routine helps older women maintain independence and prevent falls.

Caring for the underserved: using patient and physician focus groups to inform curriculum development.

BACKGROUND: Training pediatric residents to care for the underserved is a recognized curricular need. A literature review revealed that curricula specific to caring for the underserved tend to focus on specific medical diagnoses rather than physician or patient behaviors. OBJECTIVE: To collect and evaluate information essential for developing a curriculum to teach care for the underserved. METHODS: Focus groups were conducted to identify themes responsive to the question, "What does a physician need to know to care for the underserved?" Each of 3 focus groups met twice. The physician group included 5 pediatricians and 3 family practitioners. There were 2 patient groups: one Spanish-speaking (N = 13) and one English-speaking (N = 8). Content analysis was used to identify themes from each of the focus groups. RESULTS: Prevailing themes from the 3 groups were communication/respect, cultural issues, and frustration with systems, such as health insurance, transportation, and health delivery systems. Patients expressed an almost universal wish for physicians to listen to them and to attempt to "understand my life." Physicians expressed concerns with lacking the time to establish quality patient relationships and the need to serve multiple roles. The groups did not discuss issues related to specific medical conditions. CONCLUSIONS: Physicians and underserved patients identified communication/respect, cultural issues, and frustration with systems, such as health insurance, transportation, and health delivery systems, as important factors in caring for the underserved. Curricula to teach care of the underserved should include these themes.

Musculoskeletal curricula in medical education: filling in the missing pieces.

It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment.