General Internal Medicine Faculty Research Articles

Gendered Expectations: the Impact of Gender, Evaluation Language, and Clinical Setting on Resident Trainee Assessment of Faculty Performance.

Gender inequity is pervasive in academic medicine. Factors contributing to these gender disparities must be examined. A significant body of literature indicates men and women are assessed differently in teaching evaluations. However, limited data exist on how faculty gender affects resident evaluation of faculty performance based on the skill being assessed or the clinical practice settings in which the trainee-faculty interaction occurs. Evaluate for gender-based differences in the assessment of general internal medicine (GIM) faculty physicians by trainees in inpatient and outpatient settings. Retrospective cohort study SUBJECTS: Inpatient and outpatient GIM faculty physicians in an Internal Medicine residency training program from July 1, 2015, to December 31, 2018. Faculty scores on trainee teaching evaluations including overall teaching ability and Accreditation Council for Graduate Medical Education (ACGME) competencies (medical knowledge [MK], patient care [PC], professionalism [PROF], interpersonal and communication skills [ICS], practice-based learning and improvement [PBLI], and systems-based practice [SBP]) based on the institutional faculty assessment form. In total, 3581 evaluations by 445 trainees (55.1% men, 44.9% women) assessing 161 GIM faculty physicians (50.3% men, 49.7% women) were included. Male faculty were rated higher in overall teaching ability (male=4.69 vs. female=4.63, p=0.003) and in four of the six ACGME competencies (MK, PROF, PBLI, and SBP) based on our institutional evaluation form. In the inpatient setting, male faculty were rated more favorably for overall teaching (male = 4.70, female = 4.53, p=<0.001) and across all ACGME competencies. The only observed gender difference in the outpatient setting favored female faculty in PC (male = 4.65, female = 4.71, p=0.01). Male and female GIM faculty performance was assessed differently by trainees. Gender-based differences were impacted by the setting of evaluation, with the greatest difference by gender noted in the inpatient setting.

Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study.

Background:Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes.Methods:Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program.Results:From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey.Interpretation:Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents’ overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.

Abstract 233: Quality of Collaboration Between Cardiologists and Internists During Inpatient Consultations

Background: Collaboration between cardiologists and internists is essential to providing safe, effective, and patient-centered cardiovascular care. The objective of this study was to determine the quality of collaboration between these clinicians during inpatient consultations and identify areas for improvement. Methods: We surveyed hospitalists, general internal medicine faculty, and resident physicians from inpatient general medicine services and consulting cardiology attendings and fellows at a large tertiary care hospital over a two month period. Respondents were asked to rate each other’s level of collaboration on a 5-point ordinal response scale and answer multiple choice and free-response questions on consultation practices and personal preferences. Results: Overall, 92 of 155 (59%) eligible hospitalists, general internal medicine faculty, and resident physicians completed the primary survey. Collaboration with cardiology consultants was rated as high or very high quality by 72% of respondents. There was no significant difference between ratings of collaboration quality based on respondents’ level of training. Internists identified resistance or disagreement with indication for consultation, difficulty receiving a timely response, and poor follow-up communication as the largest barriers to high quality collaboration. Most internists preferred receiving recommendations by page, phone, or written in a consult note, rather than in person. Internists appreciated close communication throughout the consultation process. For longitudinal consultations, internists preferred when an intention to sign-off was communicated by page or wrote in that day’s consult note. In total, 9 cardiology attendings and fellows completed the specialty survey. Cardiologists reported providing recommendations the same day for routine consultations, or within 2-3 hours when urgent. Most consultants communicated their recommendations thru page, phone conversations, or written consult note. Providing recommendations in person was rare. Half of cardiology attendings and fellows rated collaboration with internists as high or very high quality. There was no significant difference between their ratings of collaboration with hospitalists and residents. Cardiologists appreciated when outside hospital records had already been obtained. They identified receiving an unclear reason for consult, consulting prior to initial work-up, late in the day, or when an outpatient appointment was more appropriate as the largest barriers to high quality collaboration. Conclusions: While cardiologists and internists appear to agree on modes of communication, they have different perceptions of timeliness and disagreements on appropriateness of consultations. Further research is needed to design and study interventions that address these barriers to high quality collaboration.

An Academic Research Coach: An Innovative Approach to Increasing Scholarly Productivity in Medicine.

Academic faculty who devote most of their time to clinical work often struggle to engage in meaningful scholarly work. They may be disadvantaged by limited research training and limited time. Simply providing senior mentors and biostatistical support has limited effectiveness. We aimed to increase productivity in scholarly work of hospitalists and internal medicine physicians by integrating an Academic Research Coach into a robust faculty development program. This was a pre-post quality improvement evaluation. This was conducted at the University of Washington in faculty across three academic-affiliated hospitals and 10 academic-affiliated clinics. Participants were hospitalists and internists on faculty in the Division of General Internal Medicine at the University of Washington. The coach was a 0.50 full time equivalent health services researcher with strong research methods, project implementation, and interpersonal skills. The coach consulted on research, quality improvement, and other scholarship. We assessed the number of faculty supported, types of services provided, and numbers of grants, papers, and abstracts submitted and accepted. The coach consulted with 49 general internal medicine faculty including 30 hospitalists who conducted 63 projects. The coach supported 13 publications, 11 abstracts, four grant submissions, and seven manuscript reviews. Forty-eight faculty in other departments benefited as co-authors. Employing a dedicated health services researcher as part of a faculty development program is an effective way to engage clinically oriented faculty in meaningful scholarship. Key aspects of the program included an accessible and knowledgeable coach and an ongoing marketing strategy.

The benefits of interprofessional learning and teamwork in primary care ambulatory training settings

Abstract Background New skills for assembling, working effectively in, and leading teams are needed to prepare the next generation of health professionals who work in outpatient settings. Purpose To report on a qualitative analysis conducted with 27 residency primary care training programs that included multiple health professional learners. Methods Twenty-seven focus groups were conducted with family medicine, general internal medicine and general pediatrics faculty, clinic staff, and diverse groups of learners to identify benefits of learning together in ambulatory primary care practices. Independent and consensus open and axial coding techniques applied to focus group field notes with consensus meetings identified emergent themes. Discussion Four themes were beneficial: Development of Personal Relationships, Improved Education, Improved Patient Care and Improved Job Satisfaction. Enablers to realizing benefits involved leadership support, co-location of learners and having adequate space for team huddles, which allowed health professionals to collaborate and learn together. Barriers to achieving benefits included top-down leadership approaches, poor communication, and lack of knowledge of roles and professions. Inadequate staffing, space constraints, scheduling challenges and clinic productivity pressures made interprofessional learning difficult. Conclusions Clinic culture, structures and operations both enable or create barriers to interprofessional learning.

Impact of Medical Scribes on Physician and Patient Satisfaction in Primary Care.

Use of electronic health records (EHRs) is associated with physician stress and burnout. While emergency departments and subspecialists have used scribes to address this issue, little is known about the impact of scribes in academic primary care. Assess the impact of a scribe on physician and patient satisfaction at an academic general internal medicine (GIM) clinic. Prospective, pre-post-pilot study. During the 3-month pilot, physicians had clinic sessions with and without a scribe. We assessed changes in (1) physician workplace satisfaction and burnout, (2) time spent on EHR documentation, and (3) patient satisfaction. Six GIM faculty and a convenience sample of their patients (N = 325) at an academic GIM clinic. A 21-item pre- and 44-item post-pilot survey assessed physician workplace satisfaction and burnout. Physicians used logs to record time spent on EHR documentation outside of clinic hours. A 27-item post-visit survey assessed patient satisfaction during visits with and without the scribe. Of six physicians, 100% were satisfied with clinic workflow post-pilot (vs. 33% pre-pilot), and 83% were satisfied with EHR use post-pilot (vs. 17% pre-pilot). Physician burnout was low at baseline and did not change post-pilot. Mean time spent on post-clinic EHR documentation decreased from 1.65 to 0.76h per clinic session (p = 0.02). Patient satisfaction was not different between patients who had clinic visits with vs. without scribe overall or by age, gender, and race. Compared to patients 65years or older, younger patients were more likely to report that the physician was more attentive and provided more education during visits with the scribe present (p = 0.03 and 0.02, respectively). Male patients were more likely to report that they disliked having a scribe (p = 0.03). In an academic GIM setting, employment of a scribe was associated with improved physician satisfaction without compromising patient satisfaction.

Prospective evaluation of cardiac ultrasound performance by general internal medicine physicians during a 6-month faculty development curriculum

BackgroundPoint-of-care (POCUS) education is rapidly expanding within medical schools and internal medicine residency programs, but lack of trained faculty is a major barrier. While POCUS training can improve short-term outcomes, knowledge and skills rapidly decay without deliberate practice and feedback. The purpose of this study was to evaluate the performance of focused cardiac ultrasound (FCU) by volunteer general internal medicine (GIM) faculty participating in a longitudinal POCUS curriculum.MethodsParticipants: Nine GIM clinician-educators participated in a 6-month POCUS curriculum. Faculty performance was compared to three cardiology fellows. Three diagnostic cardiac sonographers (DCS) were also evaluated and served as the gold standard. Evaluation: the primary outcome was a FCU efficiency score, calculated by dividing image quality score by exam duration. FCU exams were conducted on three standardized patients after completion of an introductory workshop, at 3 months, and at 6 months. Two blinded cardiologists scored the exams. Analysis: mean efficiency scores were compared using a linear mixed effects model, followed by pairwise comparisons using Tukey’s test.ResultsGIM faculty’s FCU efficiency scores were maintained over the 6-month period (2.2, SE 1.0 vs. 3.8, SE 1.0, p = 0.076). Their scores at each session were similar to cardiology fellows (p > 0.69), but inferior to DCSs (p < 0.0001).ConclusionGIM faculty participating in a POCUS curriculum maintained their FCU performance over 6 months with efficiency scores comparable to experienced cardiology fellows.

Point-of-care ultrasound as a competency for general internists: a survey of internal medicine training programs in Canada

Point-of-care ultrasound (POCUS) is increasingly used on General Internal Medicine (GIM) inpatient services, creating a need for defined competencies and formalized training. We evaluated the extent of training in POCUS and the clinical use of POCUS among Canadian GIM residency programs. Internal Medicine trainees and GIM Faculty at the University of Toronto were surveyed on their clinical use of POCUS and the extent of their training. We separately surveyed Canadian IM Program Directors and Division Directors on the extent of POCUS training in their programs, barriers in the implementation of POCUS curricula, and recommendations for POCUS competencies in IM. A majority of IM trainees (90/118, 76%) and GIM Faculty (15/29, 52%) used POCUS clinically. However, the vast majority of resident (111/117, 95%) and GIM Faculty (18/28, 64%) had received limited training. Of the Program Leaders surveyed, half (9/17, 53%) reported POCUS clinical use by their trainees; however only one quarter (4/16, 25%) reported offering formal curricula. Most respondents agreed that POCUS training should be incorporated into IM residency curricula, specifically for procedural guidance. A considerable discrepancy exists between the clinical use of POCUS and the extent of formal training among Canadian IM residents and GIM Faculty. We propose that formalized POCUS training should be incorporated into IM residency programs, GIM fellowships, and Faculty development sessions, and identify POCUS skills that could be incorporated into future IM curricula.

Patients’ Attitudes About Electronic System Messaging with Physicians

Objectives: To conduct a survey of patients who have and have not signed on to an electronic messaging system about their attitudes toward electronic messaging with physicians. Methods: A convenience sample of 500 patients in a university general internal medicine faculty practice completed a survey which used 12 hypothetical scenarios involving clinical problems using electronic messaging or telephone/in office visit to communicate with physicians. The number of correct responses to scenarios was used to compare electronic messaging users and non-users using student’s T test. Results: About 2/3 of respondents had signed up for the electronic messaging system. A large portion of respondents (27-59%) incorrectly used electronic messaging in the hypothetical scenarios. Patients who had signed up for electronic messaging were significantly more likely to appropriately use electronic messaging than those who had not signed up for it (p < 0.001). Conclusions: Patients may have different attitudes from those of physicians about the use of electronic messaging for symptoms of an urgent nature and receiving sensitive test results. Those patients who have not signed up for electronic messaging are particularly at risk for misperceptions. Practice Implications: All patients using electronic messaging should be educated and given guidelines about its appropriate use.

Contraceptive counseling by general internal medicine faculty and residents.

Almost half of US pregnancies are unintended, resulting in many abortions and unwanted or mistimed births. Contraceptive counseling is an effective tool to increase patients' use of contraception. Using an online 20-item questionnaire, we evaluated the frequency of contraceptive counseling provided to reproductive-age women during a prevention-focused visit by University of Colorado internal medicine resident and faculty providers. We also evaluated factors hypothesized to affect contraceptive counseling frequency. Although more than 95% of the 146 medicine faculty and resident respondents agreed that contraceptive counseling is important, only one-quarter of providers reported providing contraceptive counseling "routinely" (defined as ≥80% of the time) to reproductive-age women during a prevention-focused visit. Providing contraceptive counseling routinely was strongly associated with taking an abbreviated sexual history "often"/"routinely" (odds ratio [OR]=11.6 [3.3 to 40.0]) and with high self-efficacy to provide contraceptive counseling (OR=6.5 [1.5 to 29.0]). However, fewer than two-thirds of providers reported taking an abbreviated sexual history "often"/"routinely." More than 70% of providers reported inadequate knowledge of contraceptive methods as a contraceptive counseling barrier. However, providers' perceived inadequate knowledge was not associated with traditional educational exposures, such as lectures and women's health electives. In prevention-focused visits with reproductive-age women, a minority of internal medicine faculty and residents reported routine contraceptive counseling. Future efforts to increase contraceptive counseling among internists should include interventions that increase provider contraceptive counseling self-efficacy and ensure that providers obtain an abbreviated sexual history.

Enhancing Patient-Centered Care: SGIM and Choosing Wisely

One of the touchstones of academic General Internal Medicine, whether practiced in an ambulatory care setting or at the patient’s bedside, is its focus on enhancing and teaching patient-centered care. In an era of increasing cost consciousness, patient centeredness requires thoughtful, ongoing discussions about the risks and benefits of a myriad of medical tests and procedures. Against this backdrop, the Society of General Internal Medicine (SGIM) chose to participate in the American Board of Internal Medicine Foundation’s Choosing Wisely initiative. The Choosing Wisely initiative aims to promote conversations between patients and their physicians around tests and procedures whose necessity should be questioned and whose potential harms and benefits clarified within the context of each patient’s care plan. To date, 54 medical societies and 17 consumer groups have identified 280 potentially unnecessary medical tests and treatments that are commonly performed in the United States. 1 To further assist patients in engaging with their physicians in discussions about these tests and procedures, Consumer Reports is partnering in this process to develop and disseminate materials for patients through large, publically oriented consumer groups. This alliance of science, advocacy and policy is ultimately designed to improve patient care and clinical outcomes, and reduce wasteful and unnecessary healthcare expenditures. In discussing health care costs and the Choosing Wisely approach, Castle and Guest from the American Board of Internal Medicine (ABIM) Foundation note, “The initial focus should be on overuse of medical resources, which not only is a leading factor in the high level of spending on healthcare but also places patients at risk of harm.” 2 Some estimates suggest that as much as 30 % of all healthcare spending is wasteful. 3 Volpp and colleagues also identify the promise of the Choosing Wisely initiative when they note, “The Choosing Wisely initiative represents an important first step toward the identification of low-value services, more meaningful because it is a step taken jointly by consumer groups and professional societies.” 4 They go on to note, “Given fiscal realities, reducing low-value services is what will allow continued support for the coverage of high-value services.” 4 The ad hoc SGIM Choosing Wisely Committee was selected from the existing SGIM Clinical Practice Committee, and the Evidence-based Medicine Task Force, as well as selected society members. The goal of the ad hoc committee was to identify important topics for academic general internal medicine faculty across the spectrum of clinical practice. The committee operated under a few notable constraints. First, there had to beexistingevidence onthe selected topic, as there was no opportunity to construct new systematic reviews or evidence syntheses as part of the process. Second, the Choosing Wisely initiative was limited to five topics or

The Use of Clinical Decision‐Support Tools to Facilitate Geriatric Education

Innovative methods are needed to incorporate effective geriatric education into internal medicine residency programs. The purpose of this report is to describe the development and use of clinical decision-support (CDS) tools to facilitate geriatric education and improve the care delivered to older adults in an academic internal medicine residency ambulatory care clinic. Starting in 2009, CDS tools were implemented as a major strategy of an initiative to improve resident physician clinical competencies in geriatrics and improve the quality of care and quality of life of older adults. These tools, designed to improve resident assessment and action for each of three educational modules (falls, vision, and dementia) were embedded within the ambulatory electronic medical record (EMR) and provided a method of point-of-care training to residents caring for older adults. One hundred internal medicine residents supervised by 17 general internal medicine faculty members participated. Data regarding CDS use and associated outcomes were recorded and extracted from the ambulatory clinic EMR. Residents screened between 67% and 88% of eligible patients using CDS algorithms; rates of additional assessment and referral or further examination reflected the prevalence of the condition in the patient population. Although further development may be necessary, CDS tools are a promising modality to supplement geriatric postgraduate education while simultaneously improving patient care.

Faculty staff perceptions of feedback to residents after direct observation of clinical skills

Performance-based workplace assessments are increasingly important in clinical training. Given the inaccuracy of self-assessment, the provision of external feedback to residents about their clinical skills is necessary for the development of expertise. However, little is known about the processes used by faculty members in giving feedback to residents after observing them with patients. This study explores the factors that underpin faculty members' decisions regarding the feedback they give to residents after directly observing them with patients and the factors that influence how feedback is delivered. In 2009, 44 general internal medicine faculty staff responsible for out-patient resident teaching from 16 internal medicine residency programmes watched four videotaped scenarios and two live scenarios of standardised residents (SRs) with standardised patients and rated the SRs using the mini-clinical evaluation exercise (mini-CEX) format. Faculty staff also provided feedback to the SRs after the live encounters. After each encounter, faculty staff were individually interviewed using a semi-structured interview. Interviews were videotaped, transcribed and analysed using grounded theory methods. Two broad themes were identified in faculty members' descriptions of the feedback process: variability in feedback techniques, and the factors that influence how faculty staff think and feel about delivering feedback. Multiple approaches to feedback delivery were observed. Faculty members' tensions in balancing positive and negative feedback, their own perceived self-efficacy, their perceptions of the resident's insight, receptivity, skill and potential, the faculty member-resident relationship and contextual factors impacted the feedback process. The provision of feedback by faculty staff to residents after observing resident-patient interactions is a complex and dynamic process and is influenced by many factors. Understanding these cognitive and affective factors may provide insight into potential new approaches to faculty development to improve faculty staff's feedback skills and the effectiveness of their feedback.

Opening the black box of clinical skills assessment via observation: a conceptual model

This study was intended to develop a conceptual framework of the factors impacting on faculty members' judgements and ratings of resident doctors (residents) after direct observation with patients. In 2009, 44 general internal medicine faculty members responsible for out-patient resident teaching in 16 internal medicine residency programmes in a large urban area in the eastern USA watched four videotaped scenarios and two live scenarios of standardised residents engaged in clinical encounters with standardised patients. After each, faculty members rated the resident using a mini-clinical evaluation exercise and were individually interviewed using a semi-structured interview. Interviews were videotaped, transcribed and analysed using grounded theory methods. Four primary themes that provide insights into the variability of faculty assessments of residents' performance were identified: (i) the frames of reference used by faculty members when translating observations into judgements and ratings are variable; (ii) high levels of inference are used during the direct observation process; (iii) the methods by which judgements are synthesised into numerical ratings are variable, and (iv) factors external to resident performance influence ratings. From these themes, a conceptual model was developed to describe the process of observation, interpretation, synthesis and rating. It is likely that multiple factors account for the variability in faculty ratings of residents. Understanding these factors informs potential new approaches to faculty development to improve the accuracy, reliability and utility of clinical skills assessment.

Valuing the Education Mission: Implementing an Educational Value Units System

Valuing the Education Mission: Implementing an Educational Value Units System

Is Looking Older than One’s Actual Age a Sign of Poor Health?

Physicians often begin the physical examination with an assessment of whether a patient looks older than his or her actual age. This practice suggests an implicit assumption that patients who appear older than their actual age are more likely to be in poor health. To determine the sensitivity and specificity of apparent age for the detection of poor health status. Cross-sectional. A total of 126 outpatients (ages 30-70) from four primary care clinics and one general internal medicine clinic at an academic medical institution. With the patient's actual age provided, physicians (n = 58 internal medicine residents and general internal medicine faculty) viewed patient photographs and assessed how old each patient looked. For each physician, we examined the sensitivity and specificity of the difference between how old the patient looked and the patient's actual age for the detection of poor health, defined using SF-12 physical health and mental health scores. Using the threshold of looking ≥ 5 years older than actual age and with poor health defined as an SF-12 score ≥ 2.0 SD below age group norms, median sensitivity was 29% (IQR, 19% to 35%), median specificity 82% (IQR, 77% to 88%), median positive likelihood ratio 1.7 (IQR, 1.3 to 2.2), and median negative likelihood ratio 0.9 (IQR, 0.8 to 0.9). Using the threshold of looking ≥ 10 years older than actual age, median sensitivity was 5% (IQR, 2% to 9%) and median specificity was 99% (IQR, 96% to 100%). The diagnostic value of apparent age depends on how many years older than his or her actual age a patient looks. A physician's assessment that a patient looks ≥ 10 years older than his or her actual age has very high specificity for the detection of poor health.

The Curriculum for the Hospitalized Aging Medical Patient program: A collaborative faculty development program for hospitalists, general internists, and geriatricians

The University of Chicago Curriculum for the Hospitalized Aging Medical Patient (CHAMP) faculty development program (FDP) is targeted at hospitalists and other internists who teach residents and students in the hospital setting. The aim of CHAMP is to increase the quantity and quality of teaching of geriatric medicine pertinent to the inpatient setting. Hospitalist and general internist faculty members who attend on the University of Chicago Medicine teaching service were invited to participate. The CHAMP FDP consisted of twelve 4-hour sessions. Two hours of each session covered inpatient geriatrics content, and 2 hours addressed improving clinical teaching (both general teaching skills and challenges specific to the inpatient wards) and teaching the Accreditation Council for Graduate Medical Education core competencies with geriatrics content. The evaluation included a self-report survey of the impact on the graduates' teaching and clinical practice. The FDP was piloted in early 2004 with a core group of geriatrics and hospitalist faculty. Three subsequent cohorts totaling 29 hospitalist and general internal medicine faculty members completed the FDP by the fall of 2006. Faculty participants evaluated the program positively, and significant improvements in knowledge, attitudes to geriatrics, and perceived behavior in teaching and practicing geriatrics skills were found. The integration of teaching techniques and geriatrics content was enthusiastically accepted by University of Chicago hospitalists and general internists who teach residents and medical students in the inpatient setting. The program has potential for widespread suitability to all teaching faculty who care for the older hospitalized patient.

Direct Observation of Faculty With Feedback: An Effective Means of Improving Patient-Centered and Learner-Centered Teaching Skills

Background: In 2002 Lehigh Valley Hospital and Health Network Internal Medicine residency program sought to establish a faculty development program for their teaching faculty that emphasized learner-centered teaching of patient-centered care. Description: Medical educators trained in observational research practices shadowed teaching teams for 24 months and observed 24 General Internal Medicine faculty teach on inpatient rounds and provided timely written feedback to faculty. Within 48 hr, faculty received a completed Observation Feedback Sheet and summary comments. Evaluation: Teaching skills were seen to improve over time after feedback was provided and repeat observations occurred. Observation ratings mirrored the results of the established Department of Medicine resident ranking of faculty teaching: Observed faculty receiving feedback improved their ranking, whereas faculty not observed did not. Conclusions: Observation of teaching with written feedback is an effective means of individualizing faculty development and improving learner-centered 4 and microskill 7 teaching of patient-centered care. 8

The interpersonal, cognitive and efficiency domains of clinical teaching: construct validity of a multi-dimensional scale

We are unaware of any hypothesis-driven studies showing that teaching assessments are comprised solely of interpersonal and cognitive domains. Moreover, previous teaching assessments have been biased by heterogeneous samples of evaluators. Consequently, we investigated the construct validity of faculty assessments comprised of interpersonal and cognitive domains, utilising evaluations obtained from resident doctors on an internal medicine hospital service. A total of 1000 inpatient evaluations were completed on 60 general internal medicine faculty members. Education theory supported a 2-dimensional, 14-item scale. Principal factor analysis was used to explore the scale's dimensionality. Internal reliability and interobserver agreement were determined. Relationships between domains and instructor characteristics were also examined. Principal factor analysis revealed interpersonal, clinical teaching and efficiency domains. Internal reliabilities of all domains are high (alpha > 0.90). Interobserver agreement is good (range 0.64-0.83). In the interpersonal domain there is a trend towards higher scores for lower ranking faculty. Significant findings are higher overall scores in the interpersonal domain (P < 0.001), higher scores for assistant professors in the interpersonal domain (P = 0.008) and higher scores for male than female faculty in the interpersonal (P = 0.041) and clinical teaching (P = 0.008) domains. Clinical teaching evaluations are reducible to interpersonal, clinical teaching and efficiency domains. Evidence for construct validity includes predicted domains and high internal and interobserver reliabilities. Utilising a homogenous sample of evaluators minimised variance. Interestingly, lower ranking faculty scored higher in the interpersonal domain, suggesting that lower ranking faculty may focus more attention on teaching activities than full professors do.

Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting

The purpose of this study was to determine whether "clinical inertia"-inadequate intensification of therapy by the provider-could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.