Practice Residency Training Research Articles

Group Prenatal Care: A Promising Quality Measure in Ambulatory Obstetrics [28A

INTRODUCTION: The group prenatal care (GPC) practice model has demonstrated success in achieving quality goals such as improved outcomes, care satisfaction and reduced costs. We sought to improve care quality among women receiving prenatal care in an urban, obstetrical residency training practice by implementing a GPC option. METHODS: We conducted a retrospective study comparing women in a GPC pilot cohort to a risk-based, matched cohort of women receiving individual prenatal care in the same practice from 2015 to 2018. Maternal and newborn outcomes and cost were assessed. Descriptive analysis was used to characterize the cohorts and bivariate analysis was used to compare outcomes and costs. Date were obtained from electronic medical records and hospital financial systems. RESULTS: Rates of cesarean delivery (17.9% vs 33%, p = 0.04) and neonatal intensive care unit (NICU) admissions (1.8% vs 17%, p = <0.01) were decreased among women in the GPC cohort compared to those in individual care. Reduced NICU admissions saved the Medicaid program approximately $256,216 or $37,027 per avoided admission. CONCLUSION: Few ambulatory quality metrics are defined in obstetrical care. GPC implemented in an urban, residency training practice setting improved outcomes and reduced costs compared to those in individual prenatal care. GPC is a promising model to improve quality among ambulatory obstetrics training practices.

Empanelment in a Resident Teaching Practice: A Cornerstone to Improving Resident Outpatient Education and Patient Care.

Improving continuity is challenging in residency training practices. Studies have shown that empanelment enables high-performing primary care and is foundational to improve accountability and continuity. An empanelment process was created in a large, urban, residency training practice as an effective approach to enhancing continuity among residents and their patients. In 2016, we formed an empanelment committee that included stakeholders from the department of medicine, the internal medicine residency program, and hospital and IT leadership. This committee set goal panel sizes, selected an empanelment algorithm, determined which patients needed re-empanelment, and facilitated medical record integration. Empanelment was followed and reassessed quarterly for 2 years. We measured anticipated visit demand using visits in the prior year and continuity using the continuity for physician formula. Of 18 495 active patients in July 2016, 8411 (45%) were assigned a new PCP in the empanelment process. At baseline, panel sizes and expected visit demand were highly variable among residents (from 40 to 107 and 120 to 480, respectively). Empanelment led to more equivalent panel sizes and expected visit demand across same year residents (eg, PGY-3: 80-100 and 320-440, respectively). Continuity for all PCPs in the practice improved from 63% before empanelment to over 80% after empanelment, and improved from 55% to 72% for individual residents. In a large and complex practice environment, we were able to empanel resident clinic patients to improve continuity and maintain it over 2 years.

Integrating Systems-Based Practice, Community Psychiatry, and Recovery Into Residency Training

Behavioral health services involving multiple systems of care are increasingly being provided in community as well as hospital settings. Residents therefore should be familiar with multiple systems and the role of the psychiatrist in these systems. The authors describe a curriculum incorporating principles of systems-based practice (SBP), community psychiatry, and recovery. This curriculum was designed to include lectures, clinical rotations, specialized written/oral presentations, and supervision focused on SBP and recovery principles. Residents also participate in home and site visits for further immersion into the multiple systems that their patients have to navigate. The essential elements of this curriculum are the 1) consistent review and emphasis on the four researched-based SBP roles of the psychiatrist; 2) recovery principles of person-centered care and shared decision-making; 3) requirement that residents interact with patients in community and home settings; 4) integration of didactic courses and clinical rotations; and 5) focus on the supervisor/supervisee relationship.

Promoting patient-centred care through trainee feedback: Assessing Residents' C-I-CARE (ARC) Program

AimsIn recent years, patient satisfaction has been integrated into residency training practices through core competency requirements as set forth by the Accreditation Council of Graduate Medical Education (ACGME). In 2006,...

Meeting the Challenge of Practice Quality Improvement: A Study of Seven Family Medicine Residency Training Practices

Incorporating quality improvement (QI) into resident education and clinical care is challenging. This report explores key characteristics shaping the relative success or failure of QI efforts in seven primary care practices serving as family medicine residency training sites. The authors used data from the 2002-2008 Using Learning Teams for Reflective Adaptation study to conduct a comparative case analysis. This secondary data analysis focused on seven residency training practices' experiences with the reflective adaptive process (RAP), a 12-week intensive QI process. Field notes, meeting notes, and audiotapes of RAP meetings were used to construct case summaries. A matrix comparing key themes across practices was used to rate practices' QI progress during RAP on a scale of 0 to 3. Three practices emerged as unsuccessful (scores of 0-1) and four as successful (scores of 2-3). Larger practices with previous QI experience, faculty with extensive exposure to QI literature, and an office manager, residency director, or medical director who advocated the process made substantial progress during RAP, succeeding at QI. Smaller practices without these characteristics were unable to do so. Successful practices also engaged residents in the QI process and identified serious problems as potential crises; unsuccessful practices did not. Larger residency training practices are more likely to have the resources and characteristics that permit them to create a QI-supportive culture leading to QI success. The authors suggest, however, that smaller practices may increase their chances of success by adopting a developmental approach to QI.

The American Society for Clinical Pathology Resident In-Service Examination: Does Resident Performance Provide Insight into the Effectiveness of Clinical Pathology Education?

The resident in-service examination in pathology is an in-training exercise that is taken by virtually all pathology residents in the United States as well as by some participants in Canada, Ireland, and Lebanon. Although all of the anatomic pathology topics in the examination, with only one exception-forensic pathology, show significant improvement in scores over the 4 years of residency training, three areas of clinical pathology training (laboratory administration, clinical chemistry, and microbiology) show significantly lower improvement in performance over the years of residency training. By contrast, transfusion medicine, hematopathology and the special topics section of the examination all demonstrate improved performance by residents over time. While the reason behind these differences must remain speculative at this time, these findings suggest that measures to improve effectiveness in clinical pathology training might be suggested by examining the differences between residency training practices between higher and lower performing areas of clinical pathology.

Pain Relief for Neonatal Circumcision: A Follow-up of Residency Training Practices

To assess current training practices regarding the provision of effective analgesia for routine newborn circumcision. All family practice (FP), obstetric and gynecologic (OB/GYN), and pediatric (PED) residency program directors in the United States received a mailed survey in 2003 (N = 940). Survey responses were received from 86% (811/940) of the programs (FP 88%, OB/GYN 82%, and PED 87%). Eighty-two percent (669/811) of all programs surveyed taught circumcision (FP 95%, OB/GYN 89%, and PED 49%). Of programs that taught circumcision, 97% (648/669) taught the administration of an anesthetic, either locally or topically. This proportion is significantly higher than that reported in 1998 (71%, 374/527; P < .001). However, of these same programs that taught circumcision, the anesthetic techniques were used frequently or always in only 84%. The percentage of training programs that teach effective analgesia for neonatal circumcision increased dramatically since the time of the previous data collection. Despite this improvement in teaching practices, some training programs may not consistently use effective analgesia for neonatal circumcision.

Supervision and Boundaries in a Combined Family Practice and Psychiatry Residency Training Program: The National Capital Consortium Experience

The combined discipline of family practice and psychiatry was created in 1995. There are no established guidelines for 1) teaching residents how to integrate these two specialties, 2) providing appropriate supervision, and 3) helping residents develop personal and professional boundaries. The authors share their approach and aim to stimulate dialogue and promote the establishment of standards for combined programs. The authors review some of the difficulties encountered in supervising family practice-psychiatry residents and the rationale for their approach. Providing residents with clear boundaries of practice and supervision that initially separate the two specialties during training facilitates the development of specialty knowledge and skills as well as the capacity to form clear boundaries. Our experience suggests that only when residents learn the appropriate practice and boundaries of each specialty can they successfully integrate the two without boundary or role confusion.

Combined Family Practice and Psychiatry Residency Training: A 10-Year Appraisal

Combined Family Practice and Psychiatry Residency Training: A 10-Year Appraisal

New ACGME Work-Hour Guidelines and Their Impact on Current Residency Training Practices

Accreditation Council for Graduate Medical Education (ACGME) has introduced new work-hour guidelines for residents in ACGME accredited programs that were implemented in July 2003. The new ACGME policies impact several practices in various psychiatry residency programs across the U.S., even though psychiatry has not been at the forefront of the debate regarding work hours. The authors surveyed all psychiatry residency programs in the U.S. and identified several current practices that may infringe on the new ACGME work-hour guidelines. Further interpretation of the new guidelines is needed.

Innovations in residency education: examples from general practice in the United Kingdom.

There are many similarities in the practice styles and residency training of family physicians in the United States and general practitioners in the United Kingdom. However, three important components of general practice training in the United Kingdom are not well developed in U.S. residencies. These are the final office-based training year, the summative assessment of the trainee, and region-wide educational courses. Each of these innovations offer advantages for efficient training and evaluation and is a potential model for strengthening family practice and other residencies in the United States.

Emphasizing a preventive medicine orientation during primary care/family practice residency training

In the wake of managed care, primary care physicians are expected to be gatekeepers in the overall healthcare system. As such, preventive medicine, rather than disease-oriented medicine, will play a key role in keeping medical costs in line. To that end, the authors review the current preventive medicine practices and guidelines and suggest ways in which these practices can be implemented in the training of primary care/family practice residents.

Leadership in a Clinical Profession

The contributions of residency training programs to pharmacy's development into a clinical profession are described. Residency programs supply institutional pharmacy with mature, highly skilled clinical and managerial practitioners, and ASHP's accreditation process ensures the programs' quality. Residents develop values, philosophy, and vision that breed innovation and advancement of the profession. As pharmacy departments strive to meet the standards set by the accreditation program, the level of services rises; subsequently, higher standards are established and practice advances accordingly. Future residency training for community practice and the movement toward the Pharm.D. as the sole entry-level degree for practitioners must be evaluated in terms of effect on patient care and on pharmacy school and hospital resources. Planning for future pharmacy education and manpower needs should involve the whole profession, but the needs of community and hospital pharmacy may differ. A goal for the future is entry-level residency training for all hospital pharmacists, with the Pharm.D. degree as a prerequisite. Such a residency program would focus on clinical practice and provide experience in all pharmaceutical services and the overall management of a pharmacy department; it would be a prerequisite for advanced specialized residency programs. Managers of departments providing clinical services will need an entry-level clinical residency followed by a specialized residency in administration. In their 25-year history, residency programs have contributed greatly to the profession. Efforts to develop quality residency training sites and promote them to pharmacy graduates should continue.

DIFFERENCES IN PEDIATRIC SUBSPECIALITY TRAINING REQUIREMENTS

The special requirements of the Accreditation Council for Graduate Medical Education state that the subspecialty rotations in pediatric training programs should not consume more than 11 months. No guidelines are offered concerning which subspecialties should be required or offered as electives. To examine current residency training practices we polled all pediatric residencies with at least 20 residents. Of 109 programs, 37 (34%) responded. Responses showed that the number of required subspecialty months ranged from 0 (22%) to 10 (3%) with a mean of 2.9 months. Subspecialty rotations most frequently required by pediatric training programs are: development 15 (41%), cardiology 13 (35%), hematology/oncology 13 (35%) and neurology 11 (30%). Pediatric surgery is required by 7 programs (19%), while only 6 (16%) require infectious disease and only 4 programs (11%) require experience in a practitioner's office. In addition to required rotations, elective time available for subspecialty training ranged from 4 to 10 months. Required subspecialty experiences vary widely among graduates of United States training programs. Potential explanations include differences in the perception of what knowledge and expertise are required for entry into practice as well as factors other than educational considerations, such as patient service commitment and faculty influence. Whether these differences in required subspecialty training are beneficial or detrimental requires further investigation.