Tilling the soil while sowing the seeds: combining resident education with medical home transformation.

In order to successfully integrate screening, brief intervention, and referral to treatment (SBIRT) into primary care, education of clinicians must be paired with sustainable transformation of the clinical settings in which they practice. The SBIRT Oregon project adopted this strategy in an effort to fully integrate SBIRT into 7 primary care residency clinics. Residents were trained to assess and intervene in their patients' unhealthy substance use, whereas clinic staff personnel were trained to carry out a multistep screening process. Electronic medical record tools were created to further integrate and track SBIRT processes. This article describes how a resident training curriculum complemented and was informed by the transformation of workflow processes within the residents' home clinics.

Advancing educational continuity in primary care residencies: an opportunity for patient-centered medical homes.

Continuity of care is a core value of patients and primary care physicians, yet in graduate medical education (GME), creating effective clinical teaching environments that emphasize continuity poses challenges. In this Perspective, the authors review three dimensions of continuity for patient care-informational, longitudinal, and interpersonal-and propose analogous dimensions describing continuity for learning that address both residents learning from patient care and supervisors and interprofessional team members supporting residents' competency development. The authors review primary care GME reform efforts through the lens of continuity, including the growing body of evidence that highlights the importance of longitudinal continuity between learners and supervisors for making competency judgments. The authors consider the challenges that primary care residency programs face in the wake of practice transformation to patient-centered medical home models and make recommendations to maximize the opportunity that these practice models provide. First, educators, researchers, and policy makers must be more precise with terms describing various dimensions of continuity. Second, research should prioritize developing assessments that enable the study of the impact of interpersonal continuity on clinical outcomes for patients and learning outcomes for residents. Third, residency programs should establish program structures that provide informational and longitudinal continuity to enable the development of interpersonal continuity for care and learning. Fourth, these educational models and continuity assessments should extend to the level of the interprofessional team. Fifth, policy leaders should develop a meaningful recognition process that rewards academic practices for training the primary care workforce.

Observing trainee encounters using a one-way mirror.

BACKGROUND: Direct observation of patient encounters is a key component of evaluating residents during training, but there are scarce data on the various methods of observation. AIM: To implement a novel method for direct observation of out-patient encounters via a one-way mirror in an internal medicine resident practice, and to assess the feasibility and acceptance of this method. METHODS: Each selected resident-patient encounter was directly observed by a preceptor through a one-way mirror. The preceptor provided feedback to the resident at the conclusion of each encounter. A post-visit survey assessed resident satisfaction and comfort with this method of observation. RESULTS: Using a one-way mirror was a feasible method of observation. Fifty residents had a clinic visit that was directly observed, and 42 (84%) completed the post-visit survey. Residents reported that they preferred direct observation through a one-way mirror compared with other methods, including videotaped encounters or having a preceptor physically present in the room. They also felt that having a preceptor observing through the one-way mirror had no negative effect on the clinic visit. Direct observation of patient encounters is a key component of evaluating residents CONCLUSIONS: Direct observation through a one-way mirror is a viable method in the out-patient setting, and might be preferable for evaluating certain skills.

Simulated electronic health record (Sim-EHR) curriculum: teaching EHR skills and use of the EHR for disease management and prevention.

Electronic health records (EHRs) can improve many aspects of patient care, yet few formal EHR curricula exist to teach optimal use to students and other trainees. The Simulated EHR (Sim-EHR) curriculum was introduced in January 2011 at Oregon Health & Science University (OHSU) to provide learners with a safe hands-on environment in which to apply evidence-based guidelines while learning EHR skills. Using an EHR training platform identical to the OHSU EHR system, learners review and correct a simulated medical chart for a complex virtual patient with chronic diseases and years of fragmented care. They write orders and prescriptions, create an evidence-based plan of care for indicated disease prevention and management, and review their work in a small-group setting. Third-year students complete the Sim-EHR curriculum as part of the required family medicine clerkship; their chart work is assessed using a rubric tied to the curriculum's general and specific objectives. As of January 2014, 406 third-year OHSU medical students, on campus or at remote clerkship sites, and 21 OHSU internal medicine interns had completed simulated charts.In this article, the authors describe the development and implementation of the Sim-EHR curriculum, with a focus on use of the curriculum in the family medicine clerkship. They also share preliminary findings and lessons learned. They suggest that the Sim-EHR curriculum is an effective, interactive method for providing learners with EHR skills education while demonstrating how a well-organized chart helps ensure safe, efficient, and quality patient care.

A multisite, multistakeholder validation of the Accreditation Council for Graduate Medical Education competencies.

PURPOSE: The Accreditation Council for Graduate Medical Education's (ACGME's) six-competency framework has not been validated across multiple stakeholders and sites. The objective of this study was to perform a multisite validation with five stakeholder groups. METHOD: This was a cross-sectional, observational study carried out from October to December, 2011, in the internal medicine residency continuity clinics of eight internal medicine residency programs in the Pacific Northwest, including a VA, two academic medical centers, a military medical center, and four private hospitals. The authors performed a cultural consensus analysis (CCA) and a convergent-discriminant analysis using previously developed statements based on internal medicine milestones related to the six competencies. Ten participants were included from each of five stakeholder groups: patients, nurses, residents, faculty members, and administrators from each training site (total: 400 participants). RESULTS: Moderate to high agreement and coherence for all groups were observed (CCA eigenvalue ratios ranging from 2.16 to 3.20); however, high differences in ranking order were seen between groups in four of the CCA statements, which may suggest between-group tension in these areas. Analyses revealed excellent construct validity (Zcontrast score of 5.323, P < .0001) for the six-competency framework. Average Spearman correlation between same-node statements was 0.012, and between different-node statements it was -0.096. CONCLUSIONS: The ACGME's six-competency framework has reasonable face and construct validity across multiple stakeholders and sites. Stakeholders appear to share a single mental model of competence in this learning environment. Data patterns suggest possible improvements to the competency-milestone framework.