Developing a Transitions of Care Elective for Medical Students during the COVID-19 Pandemic and Beyond.

OBJECTIVES: Health care in the United States is costly, fragmented, and often ineffective. Transitions of care (TOC), particularly from the inpatient to the outpatient setting, is an especially complicated time and one that is potentially fraught with errors that contribute to negative outcomes. The coronavirus 2019 pandemic exacerbated many of these challenges. In particular, vulnerable patient populations have experienced more barriers to successful care transitions. Effective care transitions should include interprofessional teamwork, robust patient education, and seamless communication among the various healthcare team members. Increasingly, medical schools are working toward graduating systems-ready physicians who demonstrate competency in the health system sciences and are able to operate effectively within the healthcare system, including being able to navigate complex transitions of care issues. Undergraduate medical education, however, continues to provide experiential learning in the traditional silos of inpatient versus outpatient medicine, so that learners do not have the opportunity to directly participate in transitions of care. Although transitions of care is a pivotal part of patient care, it is rarely taught at the undergraduate level, and when it is, it is typically relegated to the classroom setting. METHODS: We used the disruption of the coronavirus 2019 pandemic to develop a TOC elective. The aim was to fulfill an acute educational need and to develop competencies around care transitions for students while concurrently providing support for patient care and teamwork. The elective was offered to second-, third- and fourth-year medical students. Our educational innovation was initiated within our safety-net hospital where we care for a high percentage of uninsured patients, with a high language discordance. In addition, our city has multiple care systems without a single or connected electronic health record system, further complicating patient care transitions. The work of the TOC elective crossed inpatient and outpatient silos, with close collaboration with our local federally qualified health centers. This remotely conducted elective includes three main pillars: participation in team activities, including virtual participation in interdisciplinary rounds and care coordination; discharge planning; and communication, including goals of care and end of life communication. RESULTS: Medical students successfully integrated into team structures to directly counsel families, facilitate goals of care conversations, and engage a multidisciplinary team for discharge planning. Students found this experience valuable in their reflections. In addition, there was a value-added component from a patient care and teamwork perspective. CONCLUSIONS: Participation of students in TOC is a valuable educational experience and contributes a value-added component to patient care and interprofessional teamwork. Moreover, an appreciation of the failures of the current system is pivotal as learners start to reimagine, explore, and design improved patient-centered systems in the future.

Everyday Leadership: A Combined Resident and Faculty Workshop.

OBJECTIVES: Historically, physicians have always been viewed as leaders in the healthcare field. Whether they embrace this role, physicians often find themselves in a leadership role, from the clinical setting to an institutional setting. In most cases, this leadership role is taken on without prior training on even the most basic concepts required for effective leadership. METHODS: We created a combined leadership workshop for both faculty members and residents in training. The topics included an introduction to leadership styles, emotional intelligence, and negotiation skills. The leadership workshop was conducted as an interactive training session for faculty and resident physicians and was embedded during routinely scheduled teaching time for residents. RESULTS: We present survey data from two annual workshops, demonstrating a clear improvement in participants' perceived understanding of leadership skills in the areas of leadership style, emotional intelligence, and negotiation skills. We have found that fairly simple measures may be taken to embed this training into the busy schedules of medical faculty and residents in training and that tapping into local expertise was an effective and efficient approach to this. CONCLUSIONS: We believe the results from our experience can help inform other programs about practical approaches to teaching leadership skills.

And Now, Please Sign on the Dotted Line: Teaching Residents About Professional Life After Residency.

OBJECTIVES: Despite possible long-term repercussions, few training programs teach their residents about the business of medicine. In particular, certain contractual issues can adversely affect a young physician's career mobility. METHODS: We designed a business-of-medicine curriculum and used a survey to determine whether the curriculum satisfied attendees' perceived knowledge gaps about the topics covered in the course, which included four key contractual matters: physician employment contracts (including restrictive covenants), malpractice insurance, job search, and interviewing skills. We used a postsurvey in 2015 and added a presurvey for the course in 2016. The same content was delivered in a 1-hour conference to internal medicine residents attending a regular noon conference series in 2015 and a regional academic meeting in 2016. Survey data are presented in terms of descriptive statistics. We used χ2 tests for comparisons of pre- and post-Likert scale survey data. RESULTS: Of 108 residents, 50 returned the surveys for an overall response rate of 46% across the 2 years of the course. Overwhelmingly, residents found the conference to be beneficial to the understanding of the four key contractual matters, with each topic having a statistically significant difference in perceived knowledge between the pre- and postconference questionnaires (P < 0.001). The majority of the residents indicated that they wanted to learn more about business-of-medicine topics, in particular financial challenges (76%) and job opportunities (68%). CONCLUSIONS: Our results confirm that our curriculum is effective in increasing the residents' perceived understanding of restrictive covenants, malpractice insurance, negotiating skills, and job search. Our results also demonstrate that residents have a desire to learn more about job searches; negotiating skills; and contractual issues, including restrictive covenants and malpractice insurance.

Developing a Communication Curriculum and Workshop for an Internal Medicine Residency Program.

OBJECTIVES: Learning effective communication is essential for physicians. Effective communication has been shown to affect healthcare outcomes, including patient safety, adherence rates, patient satisfaction, and enhanced teamwork. The importance of these skills has become even more apparent in recent years, with value-based purchasing programs and federal measures of patient satisfaction in the form of Hospital Consumer Assessment of Healthcare Providers and Systems scores becoming an important part of measuring the performance of a healthcare facility. METHODS: We conducted a communication workshop for internal medicine residents at the University of Texas. Topics covered included the Acknowledge, Introduce, Duration, Explanation, Thank You framework; managing up; resolving conflicts; error disclosure; new medication and discharge counseling; intercultural communication; understanding Hospital Consumer Assessment of Healthcare Providers and Systems scores; and avoiding burnout. Because it would have been logistically difficult to block whole days for the workshop, the various topics were offered to residents during their regular noon conference hour for several consecutive days. After the workshop, the residents completed an anonymous questionnaire regarding their perception of the importance of various aspects of communication in patient care. RESULTS: The majority of the participating residents perceived the various communication skills explored during the workshop to be highly important in patient care. Concurrently, however, most residents believed that they had initially overestimated their knowledge about these various communication issues. Some demographic differences in the responses also were noted. CONCLUSIONS: Our findings demonstrate a needs gap and an area of potential improvement in medical education. We anticipate that with the growing understanding of the importance of communication skills in the healthcare setting, there will be an enhanced role for teaching these skills at all levels of medical education. More studies are needed to further elucidate the specific areas of communication in health care where additional training is necessary.

From Knowing to Doing: Integrating Systems-Ready Physician Competencies in the Clerkship Setting.

There are increasing calls to graduate physicians with a strong understanding of health systems science (HSS). Many schools have incorporated didactics on health systems science content such as quality improvement, patient safety, or interprofessional education. Creating a systems-ready physician requires more than teaching content in classroom settings. Using Miller's pyramid of assessment of clinical performance, we have developed strategies to move our learners from the cognitive-based "knows" level to the behavior-based "does" level of understanding of the HSS competencies. Our medical students begin learning HSS in classroom settings. Next, the students apply this knowledge during their core clerkships. This gives them an opportunity to get feedback increasingly from high-fidelity clinical settings. We embedded assessment strategies and tools in the clerkship year to facilitate the demonstration, observation, and assessment of HSS competencies in the setting of our core clerkships. We also have students self-assess their competence in our graduation competencies at the end of each year. Student self-assessment from the beginning of the clerkship year to the end showed significant increases in the HSS competencies. Our clerkship student assessment data from our first cohort suggest that faculty had difficulty observing and assessing some of the competencies unique to health systems science. The clerkships have developed multiple projects and assignments to allow students to demonstrate HSS competencies. Faculty and resident training to prompt, observe, and assess these competencies is ongoing to close the assessment gap. In the area of professionalism, student self-assessment and faculty clinical assessment correlate strongly.