A Patient-Centered Documentation Skills Curriculum for Preclerkship Medical Students in an Open Notes Era.

Introduction: New legislation allows patients (with permitted exceptions) to read their clinical notes, leading to both benefits and ethical dilemmas. Medical students need a robust curriculum to learn documentation skills within this challenging context. We aimed to teach note-writing skills through a patient-centered lens with special consideration for the impact on patients and providers. We developed this session for first-year medical students within their foundational clinical skills course to place bias-free language at the forefront of how they learn to construct a medical note. Methods: One hundred seventy-three first-year medical and dental students participated in this curriculum. They completed an asynchronous presession module first, followed by a 2-hour synchronous workshop including a didactic, student-led discussion and sample patient note exercise. Students were subsequently responsible throughout the year for constructing patient-centered notes, graded by faculty with a newly developed rubric and checklist of best practices. Results: On postworkshop surveys, learners reported increased preparedness in their ability to document in a patient-centered manner (presession M = 2.2, midyear M = 3.9, p < .001), as rated on a 5-point Likert scale (1 = not prepared at all, 5 = very prepared), and also found this topic valuable to learn early in their training. Discussion: This curriculum utilizes a multipart approach to prepare learners to employ clinical notes to communicate with patients and providers, with special attention to how patients and their care partners receive a note. Future directions include expanding the curriculum to higher levels of learning and validating the developed materials.

"Should I Say Something?": A Simulation Curriculum on Addressing Lapses in Professionalism to Improve Patient Safety.

Introduction: Medical students may witness lapses in professionalism but lack tools to effectively address such episodes. Current professionalism curricula lack opportunities to practice communication skills in addressing professionalism lapses. Methods: We designed a simulation curriculum to introduce professionalism expectations, provide communication tools using elements of the Agency for Healthcare Research and Quality TeamSTEPPS program, and address observed professionalism lapses involving patient safety in hierarchical patient care teams. Students were surveyed on knowledge, skills, and attitude regarding professionalism before, immediately after, and 6 months after participation. Results: Of 253 students, 70 (28%) completed baseline and immediate postsurveys, and 39 (15%) completed all surveys. In immediate postsurveys, knowledge of communication tools (82% to 94%, p = .003) and empowerment to address residents (19% to 44%, p = .001) and attendings (15% to 39%, p < .001) increased. At 6 months, 96% of students reported witnessing a professionalism lapse. Discussion: The curriculum was successful in reported gains in knowledge of communication tools and empowerment to address professionalism lapses, but few students reported using the techniques to address witnessed lapses in real life.

Cohort study of hospitalists' procedural skills: baseline competence and durability after simulation-based training.

OBJECTIVES: Hospitalists are expected to be competent in performing bedside procedures, which are associated with significant morbidity and mortality. A national decline in procedures performed by hospitalists has prompted questions about their procedural competency. Additionally, though simulation-based mastery learning (SBML) has been shown to be effective among trainees whether this approach has enduring benefits for independent practitioners who already have experience is unknown. We aimed to assess the baseline procedural skill of hospitalists already credentialed to perform procedures. We hypothesised that simulation-based training of hospitalists would result in durable skill gains after several months. DESIGN: Prospective cohort study with pretraining and post-training measurements. SETTING: Single, large, urban academic medical centre in the USA. PARTICIPANTS: Twenty-two out of 38 eligible participants defined as hospitalists working on teaching services where they would supervise trainees performing procedures. INTERVENTIONS: One-on-one, 60 min SBML of lumbar puncture (LP) and abdominal paracentesis (AP). PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome was the percentage of hospitalists obtaining minimum passing scores (MPS) on LP and AP checklists; our secondary outcomes were average checklist scores and self-reported confidence. RESULTS: At baseline, only 16% hospitalists met or exceeded the MPS for LP and 32% for AP. Immediately after SBML, 100% of hospitalists reached this threshold. Reassessment an average of 7 months later revealed that only 40% of hospitalists achieved the MPS. Confidence increased initially after training but declined over time. CONCLUSIONS: Hospitalists may be performing invasive bedside procedures without demonstration of adequate skill. A single evidence-based training intervention was insufficient to sustain skills for the majority of hospitalists over a short period of time. More stringent practices for certifying hospitalists who perform risky procedures are warranted, as well as mechanisms to support skill maintenance, such as periodic simulation-based training and assessment.

Spaced education in medical residents: An electronic intervention to improve competency and retention of medical knowledge.

BACKGROUND: Spaced education is a novel method that improves medical education through online repetition of core principles often paired with multiple-choice questions. This model is a proven teaching tool for medical students, but its effect on resident learning is less established. We hypothesized that repetition of key clinical concepts in a "Clinical Pearls" format would improve knowledge retention in medical residents. METHODS: This study investigated spaced education with particular emphasis on using a novel, email-based reinforcement program, and a randomized, self-matched design, in which residents were quizzed on medical knowledge that was either reinforced or not with electronically-administered spaced education. Both reinforced and non-reinforced knowledge was later tested with four quizzes. RESULTS: Overall, respondents incorrectly answered 395 of 1008 questions (0.39; 95% CI, 0.36-0.42). Incorrect response rates varied by quiz (range 0.34-0.49; p = 0.02), but not significantly by post-graduate year (PGY1 0.44, PGY2 0.33, PGY3 0.38; p = 0.08). Although there was no evidence of benefit among residents (RR = 1.01; 95% CI, 0.83-1.22; p = 0.95), we observed a significantly lower risk of incorrect responses to reinforced material among interns (RR = 0.83, 95% CI, 0.70-0.99, p = 0.04). CONCLUSIONS: Overall, repetition of Clinical Pearls did not statistically improve test scores amongst junior and senior residents. However, among interns, repetition of the Clinical Pearls was associated with significantly higher test scores, perhaps reflecting their greater attendance at didactic sessions and engagement with Clinical Pearls. Although the study was limited by a low response rate, we employed test and control questions within the same quiz, limiting the potential for selection bias. Further work is needed to determine the optimal spacing and content load of Clinical Pearls to maximize retention amongst medical residents. This particular protocol of spaced education, however, was unique and readily reproducible suggesting its potential efficacy for intern education within a large residency program.

Preventability of early vs. late readmissions in an academic medical center.

BACKGROUND: It is unclear if the 30-day unplanned hospital readmission rate is a plausible accountability metric. OBJECTIVE: Compare preventability of hospital readmissions, between an early period [0-7 days post-discharge] and a late period [8-30 days post-discharge]. Compare causes of readmission, and frequency of markers of clinical instability 24h prior to discharge between early and late readmissions. DESIGN, SETTING, PATIENTS: 120 patient readmissions in an academic medical center between 1/1/2009-12/31/2010. MEASURES: Sum-score based on a standard algorithm that assesses preventability of each readmission based on blinded hospitalist review; average causation score for seven types of adverse events; rates of markers of clinical instability within 24h prior to discharge. RESULTS: Readmissions were significantly more preventable in the early compared to the late period [median preventability sum score 8.5 vs. 8.0, p = 0.03]. There were significantly more management errors as causative events for the readmission in the early compared to the late period [mean causation score [scale 1-6, 6 most causal] 2.0 vs. 1.5, p = 0.04], and these errors were significantly more preventable in the early compared to the late period [mean preventability score 1.9 vs 1.5, p = 0.03]. Patients readmitted in the early period were significantly more likely to have mental status changes documented 24h prior to hospital discharge than patients readmitted in the late period [12% vs. 0%, p = 0.01]. CONCLUSIONS: Readmissions occurring in the early period were significantly more preventable. Early readmissions were associated with more management errors, and mental status changes 24h prior to discharge. Seven-day readmissions may be a better accountability measure.

Separating Residents' Inpatient and Outpatient Responsibilities: Improving Patient Safety, Learning Environments, and Relationships With Continuity Patients.

PROBLEM: Current regulations for internal medicine residency programs require scheduling that minimizes conflict between inpatient and outpatient responsibilities. To meet these regulations, the internal medicine residency program at Beth Israel Deaconess Medical Center implemented a unique scheduling model--the Alternating Call and Elective Scheduling (ACES) model-in July 2009. APPROACH: Beginning in academic year 2009-2010, the authors restructured schedules for their 95 postgraduate year 2 and 3 internal medicine residents using the ACES model. They report pre- and postimplementation housestaff responses from end-of-year program evaluation and culture-of-safety surveys, as well as residents' pre- and postintervention schedule and patient visit data. OUTCOMES: Prior to the intervention, 13/83 (16%) residents agreed that the structure of residency training minimized conflict between inpatient and outpatient responsibilities; after the intervention, 82/84 (98%) agreed with this statement. Before the intervention, 23/83 (28%) residents felt that the schedule promoted inpatient safety, compared with 83/84 (99%) after the intervention. Agreement that the schedule promoted outpatient safety went from 28/83 (34%) preintervention to 73/84 (87%) postintervention. Before the intervention, 45/84 (54%) residents felt that the schedule promoted a continuous healing relationship with continuity patients, compared with 67/84 (80%) after the intervention. After implementation, residents' continuity visits with their own patients increased by 14%, and total annual patient visits increased by 16%. NEXT STEPS: Separating residents' inpatient and outpatient responsibilities may improve patient safety, the learning environment, and resident-patient relationships. Future innovations might focus on improving patient safety and decreasing stress in the outpatient environment.

Inpatient-outpatient transitions for patients with resident primary care physicians: access and readmission.

BACKGROUND: Transition from hospitalization to postdischarge care is a vulnerable period for patients. How the experience of this transition differs for patients with resident primary care physicians is unknown. METHODS: In a single, large academic primary care practice, we examined an inception cohort of consecutive hospitalizations and postdischarge visits of hospitalized patients with resident or faculty primary care physicians between 2008 and 2013. We compared patient demographics, readmission risk, and access to outpatient care between resident and faculty primary care physicians by using generalized estimating equations to account for repeated hospitalizations. RESULTS: We documented 8161 hospitalizations among patients with resident primary care physicians and 20,844 hospitalizations among patients with faculty primary care physicians. Hospitalized patients with resident primary care physicians were generally younger, more likely to be on Medicaid, and more likely to be African American (P < .001). Patients with resident primary care physicians were less likely to be seen within 7 and 30 days of discharge (adjusted relative risk, 0.83; 95% confidence interval [CI], 0.81-0.93 at 7 days; adjusted relative risk, 0.88; 95% CI, 0.85-0.92 at 30 days) and had an increased risk of readmission within 30 days (adjusted odds ratio, 1.25; 95% CI, 1.13-1.37). They also were considerably less likely to see their own provider at first follow-up (relative risk, 0.55; 95% CI, 0.52-0.59). CONCLUSIONS: Hospitalized patients with resident primary care physicians had lower rates of timely postdischarge follow-up, higher rates of readmission, and a lower likelihood of seeing their own provider than did patients with faculty primary care physicians. These findings highlight the challenges facing academic centers for patients with resident primary care physicians.

The characteristics and impact of a hospitalist-staffed post-discharge clinic.

BACKGROUND: Limited primary care access and care discontinuities hamper care for patients following hospital discharge. As the proportion of inpatient care delivered by hospitalists continues to increase, hybrid models that incorporate hospitalists in post-discharge care may ameliorate this problem. METHODS: We established a post-discharge clinic staffed by hospitalists in a large academic urban primary care practice in October 2009. We compared visits of recently hospitalized patients seen in the post-discharge clinic with post-discharge visits elsewhere in the practice, including patient demographics, health care utilization, and duration from discharge, using generalized estimating equations to account for repeated hospitalizations. RESULTS: Patients seen in the post-discharge clinic and elsewhere in the practice were generally similar, although patients seen in the post-discharge clinic were particularly likely to be black and receive primary care from residents. Relative to other patients seen following discharge, patients in the post-discharge clinic were seen 8.45 ± 0.43 days earlier (P <.001). Among all 10,845 discharges of Healthcare Associates patients between 2009 and 2011, patients were 40% more likely to be seen within a week of discharge when the post-discharge clinic was open than when it was closed (adjusted odds ratio 1.41; 95% confidence interval, 1.25-1.57). CONCLUSION: In this primary care practice, a hospitalist-staffed post-discharge clinic was associated with substantially shorter time to first post-hospitalization visit and with improvement in the overall likelihood of an early visit among all hospitalized patients. It was particularly used by black patients and those seen by residents, in whom access tends to be most fragmented, and may represent a novel approach to the problem of post-discharge care.

Change in residents' perceptions of teaching: following a one day "Residents as Teachers" (RasT) workshop.

OBJECTIVES: The objective of this study was to assess the perceptions and attitudes of resident physicians toward teaching before and after participation in a mandatory "Residents as Teachers" (RasT) workshop in four domains: (1) setting goals and expectations, (2) use of clinical microskills in teaching, (3) evaluation and feedback, and (4) enthusiasm and preparedness toward teaching. METHODS: Pre- and postintervention questionnaires were utilized. Data were analyzed for all respondents. Subgroup analyses were performed for each academic year and for primary care versus nonprimary care specialties. RESULTS: Over a 5-year period, 15 RasT workshops were presented to 276 residents from 10 different residency programs. Eighty-six percent completed the questionnaire before participation in the workshop, and 88% completed the questionnaire immediately after participation. The difference between the mean post-RasT and pre-RasT ratings on each item was used to measure the change in that item resulting from participation in the workshop. CONCLUSION: Overall, residents' self-assessed ratings of their attitudes toward teaching were positively impacted by participation in a RasT workshop. Further subanalysis showed that residents in primary care specialties showed a significantly greater increase in their ratings than residents in nonprimary care specialties.