Integrating Interprofessional Trainees into a Complex Care Program for Veterans Experiencing Homelessness: Effects on Health Services Utilization.

PURPOSE: High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described. We aim to understand how the addition of interprofessional trainees to an ambulatory clinic caring for Veterans experiencing homelessness impacts medical and mental health services utilization. METHODS: Trainees from five professions were incorporated into an interprofessional ambulatory clinic for Veterans experiencing homelessness starting in July 2016. We performed clinic-level interrupted time series (ITS) analyses of pre- and post-intervention utilization measures among patients enrolled in this training continuity clinic, compared to three similar VA homeless clinics without training programs from October 2015 to September 2018. RESULTS: Our sample consisted of 37,671 patient- months. There was no significant difference between the intervention and comparison groups' post-intervention slopes for numbers of primary care visits (difference in slopes =-0.16 visits/100 patients/month; 95% CI -0.40, 0.08; p=0.19), emergency department visits (difference in slopes = 0.08 visits/100 patients/month; 95% CI -0.16, 0.32; p=0.50), mental health visits (difference in slopes = -1.37 visits/month; 95% CI -2.95, 0.20; p= 0.09), and psychiatric hospitalizations (-0.005 admissions/100 patients/month; 95% CI -0.02, 0.01; p= 0.62). We found a clinically insignificant change in medical hospitalizations. CONCLUSIONS: Adding continuity trainees from five health professions to an interprofessional ambulatory clinic caring for Veterans experiencing homelessness did not adversely impact inpatient and outpatient care utilization. An organized team-based care approach is beneficial for vulnerable patients and provides a meaningful educational experience for interprofessional trainees by building health professionals' capabilities to care for vulnerable populations.

Well-being for trainees caring for homeless veterans.

BACKGROUND: Health care trainees caring for homeless patients may experience stress and burnout. Reasons for this include high rates of medical and psychiatric illness and complex social needs within this patient population. This can lead to feelings of inadequacy and exhaustion among health care trainees. To address this, we developed a toolkit for trainees from multiple professions caring for homeless veterans and examined its impact on trainee well-being. METHODS: Fifteen trainees and six faculty members participated in a half-day workshop given by a national expert that demonstrated a variety of well-being practices. Trainees and faculty members then identified 14 evidence-based practices relevant to the clinic for inclusion in the well-being toolkit. Half of the tools were for personal use and half were intended for teams. We developed simple graphics demonstrating each tool, and these were displayed as posters throughout the clinic. Tools were reviewed through workshops and handouts. To assess the trainee response to the toolkit, we used validated measures of burnout, stress, resilience and mindfulness at the beginning and at the end of the academic year. Trainees also rated the value of each tool. RESULTS: Trainees did not experience burnout during the year, and nor did the stress levels change. Both resilience and mindfulness trended towards improvement. Trainees rated the team-based tools as more important than the personal tools; they were also more confident in using the team-based tools. Burnout among physicians caring for marginalised patients can originate from a sense of futility and from witnessing needless suffering DISCUSSION: Team-based well-being tools may represent a better avenue for residency programmes and training sites to pursue well-being programmes, especially for trainees caring for marginalised populations.

A medical student leadership course led to teamwork, advocacy, and mindfulness.

BACKGROUND AND OBJECTIVES: Many medical trainees seek work among underserved communities but may be unprepared to cope with the challenges. Relationship-centered qualities have been shown to promote physician resilience and prevent burnout. The UCLA-PRIME program aims to prepare medical students to work among vulnerable groups and begins with a 3-week leadership course. We describe this course and share lessons with those seeking to foster leadership, advocacy, and resiliency in our future physician workforce. METHODS: Twenty students participated in our curriculum that emphasized five competencies: leadership, advocacy, teamwork, mindfulness, and self-care. Course activities complemented the students' work as they developed a community outreach project. They assessed and reflected on their leadership, relationship, and team behaviors, were coached to improve these, learned mindfulness meditation, and participated in community forums. Our evaluation assessed course quality, project completion, leadership, mindfulness, and team relational coordination. RESULTS: Students were very satisfied with all aspects of the course. They designed a medical student elective addressing the health challenges of an incarcerated and formerly incarcerated population. While we found no change in leadership practices scores, students had high team relational coordination scores and improved mindfulness scores upon course completion. DISCUSSION: Our course to develop medical students as resilient leaders, team members, and advocates for medically underserved groups consisted of a community-based service project, coupled with a facilitated relationship-centered curriculum. It promoted qualities in students that characterize effective and resilient physician leaders; they were more mindful, related to each other effectively, and coordinated their activities well with one another.

Part-time careers in academic internal medicine: a report from the association of specialty professors part-time careers task force on behalf of the alliance for academic internal medicine.

To establish guidelines for more effectively incorporating part-time faculty into departments of internal medicine, a task force was convened in early 2007 by the Association of Specialty Professors. The task force used informal surveys, current literature, and consensus building among members of the Alliance for Academic Internal Medicine to produce a consensus statement and a series of recommendations. The task force agreed that part-time faculty could enrich a department of medicine, enhance workforce flexibility, and provide high-quality research, patient care, and education in a cost-effective manner. The task force provided a series of detailed steps for operationalizing part-time practice; to do so, key issues were addressed, such as fixed costs, malpractice insurance, space, cross-coverage, mentoring, career development, productivity targets, and flexible scheduling. Recommendations included (1) increasing respect for work-family balance, (2) allowing flexible time as well as part-time employment, (3) directly addressing negative perceptions about part-time faculty, (4) developing policies to allow flexibility in academic advancement, (5) considering part-time faculty as candidates for leadership positions, (6) encouraging granting agencies, including the National Institutes of Health and Veterans Administration, to consider part-time faculty as eligible for research career development awards, and (7) supporting future research in "best practices" for incorporating part-time faculty into academic departments of medicine.

Innovative web-based multimedia curriculum improves cardiac examination competency of residents.

BACKGROUND: Proper diagnosis of cardiac disorders is a core competency of internists. Yet numerous studies have documented that the cardiac examination (CE) skills of physicians have declined compared with those of previous generations of physicians, attributed variously to inadequate exposure to cardiac patients and lack of skilled bedside teaching. With growing concerns about ensuring patient safety and quality of care, public and professional organizations are calling for a renewed emphasis on the teaching and evaluation of clinical skills in residency training. OBJECTIVE: The objective of the study was to determine whether Web training improves CE competency, whether residents retain what they learn, and whether a Web-based curriculum plus clinical training is better than clinical training alone. Journal of Hospital Medicine 2008;3:124-133. (c) 2008 Society of Hospital Medicine. DESIGN: This was a controlled intervention study. PARTICIPANTS: The intervention group (34 internal and family medicine interns) participated in self-directed use of a Web-based tutorial and three 1-hour teaching sessions taught by a hospitalist. Twenty-five interns from the prior year served as controls. MEASUREMENTS: We assessed overall CE competency and 4 subcategories of CE competency: knowledge, audio skills, visual skills, and audio-visual integration. RESULTS: The over mean score of the intervention group significantly improved, from 54 to 66 (P = .002). This improvement was retained (63.5, P = .05). When compared with end-of-year controls, the intervention group had significantly higher end-of-year CE scores (57 vs. 63.5, P = .05), knowledge (P = .04), and audio skills (P = .01). At the end of the academic year, all improvements were retained (P

Faculty training in evidence-based medicine: improving evidence acquisition and critical appraisal.

INTRODUCTION: Evidence-based medicine (EBM) integrates published clinical evidence with patient values and clinical expertise, the output of which is informed medical decision making. Key skills for evidence-based practice include acquisition and appraisal of clinical information. Faculty clinicians often lack expertise in these skills and are therefore unable to demonstrate this process for students and residents. METHODS: We conducted a yearlong case-based EBM workshop for 28 clinician educators, with precourse and postcourse evaluations of EBM resource use and literature appraisal skills. RESULTS: Of the original 28 participants, 26 completed the course. Self-assessed EBM resource use improved significantly. Self-reported EBM knowledge correlated with measured skill (r = 0.45), and both improved with the intervention (both p < .001). Higher EBM skills scores correlated with time logged on the course's EBM Web sites (r = 0.56; p < .05), workshop attendance rates (r = 0.55; p = .003), and fewer years since medical school graduation (r = -0.56; p < .005). DISCUSSION: An interactive, longitudinal, EBM course derived from a needs assessment can improve 2 skills important for evidence-based practice: online literature retrieval and critical appraisal skills.

Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study.

BACKGROUND: Cardiac examination is an essential aspect of the physical examination. Previous studies have shown poor diagnostic accuracy, but most used audio recordings, precluding correlation with visible observations. The training spectrum from medical students (MSs) to faculty has not been tested, to our knowledge. METHODS: A validated 50-question, computer-based test was used to assess 4 aspects of cardiac examination competency: (1) cardiac physiology knowledge, (2) auditory skills, (3) visual skills, and (4) integration of auditory and visual skills using computer graphic animations and virtual patient examinations (actual patients filmed at the bedside). We tested 860 participants: 318 MSs, 289 residents (225 internal medicine and 64 family medicine), 85 cardiology fellows, 131 physicians (50 full-time faculty, 12 volunteer clinical faculty, and 69 private practitioners), and 37 others. RESULTS: Mean scores improved from MS1-2 to MS3-4 (P = .003) but did not improve or differ significantly among MS3, MS4, internal medicine residents, family medicine residents, full-time faculty, volunteer clinical faculty, and private practitioners. Only cardiology fellows tested significantly better (P<.001), and they were the best in all 4 subcategories of competency, whereas MS1-2 were the worst in the auditory and visual subcategories. Participants demonstrated low specificity for systolic murmurs (0.35) and low sensitivity for diastolic murmurs (0.49). CONCLUSIONS: Cardiac examination skills do not improve after MS3 and may decline after years in practice, which has important implications for medical decision making, patient safety, cost-effective care, and continuing medical education. Improvement in cardiac examination competency will require training in simultaneous audio and visual examination in faculty and trainees.