Amber T. Pincavage

Interventions to improve outcomes for minority adults with asthma: a systematic review

OBJECTIVESTo systematically review the literature to characterize interventions with potential to improve outcomes for minority patients with asthma.DATA SOURCESMedline, PsycINFO, CINAHL, Cochrane Trial Databases, expert review, reference review, meeting abstracts.STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTEVENTIONSMedical Subject Heading (MeSH) terms related to asthma were combined with terms to identify intervention studies focused on minority populations. Inclusion criteria: adult population; intervention studies with majority of non-White participants.STUDY APPRAISAL AND SYNTHESIS OF METHODSStudy quality was assessed using Downs and Black (DB) checklists. We examined heterogeneity of studies through comparing study population, study design, intervention characteristics, and outcomes.RESULTSTwenty-four articles met inclusion criteria. Mean quality score was 21.0. Study populations targeted primarily African American (n = 14), followed by Latino/a (n = 4), Asian Americans (n = 1), or a combination of the above (n = 5). The most commonly reported post-intervention outcome was use of health care resources, followed by symptom control and self-management skills. The most common intervention-type studied was patient education. Although less-than half were culturally tailored, language-appropriate education appeared particularly successful. Several system–level interventions focused on specialty clinics with promising findings, although health disparities collaboratives did not have similarly promising results.LIMITATIONSPublication bias may limit our findings; we were unable to perform a meta-analysis limiting the review’s quantitative evaluation.CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGSOverall, education delivered by health care professionals appeared effective in improving outcomes for minority patients with asthma. Few were culturally tailored and one included a comparison group, limiting the conclusions that can be drawn from cultural tailoring. System-redesign showed great promise, particularly the use of team-based specialty clinics and long-term follow-up after acute care visits. Future research should evaluate the role of tailoring educational strategies, focus on patient-centered education, and incorporate outpatient follow-up and/or a team-based approach.

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety

Purpose Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff. Method In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes. Results Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P < .01), more verbal handoffs (80% versus 38%, P < .01), more patients aware of the handoff (100% versus 74%, P = .01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P =.03), and more ownership of patients before the first visit (56% versus 26%, P =.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P < .01), and more tests were followed up appropriately (67% versus 46%, P = .02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P= .06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P = .06). Conclusions Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

The Chicago Breathe Project: a regional approach to improving education on asthma inhalers for resident physicians and minority patients.

BACKGROUND Asthma affects minority citizens in Chicago disproportionately. Policy changes introducing hydrofluroalkane (HFA) inhalers may worsen already-existing health disparities related to asthma. AIMS To teach internal medicine residents about the transition to HFAs so they can better counsel their patients on asthma self-management. To provide minority community members with interactive educational sessions. SETTING Internal medicine residents at 5 Chicago programs. Community workshops in primarily Spanish-speaking (Cicero) Latino population and a primarily African American population from the south side of Chicago. PROGRAM DESCRIPTION The Chicago Breathe Project provides residents with education and tools necessary to counsel patients with asthma on inhaler use and provides minority community members with interactive educational sessions on asthma and inhaler use. PROGRAM EVALUATION Eleven workshops were held across 5 academic institutions, with a total of 161 residents. Resident knowledge regarding HFA inhalers improved dramatically (5% pre vs. 91% post, p < .001). Six months post education, residents were more likely to assess inhaler technique (44% vs. 11%, p = .046) and discuss new HFA inhalers (69% vs. 24%, p = .011) with their asthma patients. Community members provided feedback after the workshops that they would come again, found the session helpful ,and enjoyed the session. DISCUSSION The Chicago Breathe Project resulted in improved resident knowledge and skill on inhaler use during HFA transition. Regional educational approaches targeting internal medicine residencies in urban areas may be helpful to address future changes in chronic disease management. This training can be taken into minority communities to provide high-quality interactive educational workshops directly to patients and their families.

Preparing for the primary care clinic: an ambulatory boot camp for internal medicine interns

Introduction Internal medicine (IM) interns start continuity clinic with variable ambulatory training. Multiple other specialties have utilized a boot camp style curriculum to improve surgical and procedural skills, but boot camps have not been used to improve interns’ ambulatory knowledge and confidence. The authors implemented and assessed the impact of an intern ambulatory boot camp pilot on primary care knowledge, confidence, and curricular satisfaction. Methods During July 2014, IM interns attended ambulatory boot camp. It included clinically focused case-based didactic sessions on common ambulatory topics as well as orientation to the clinic and electronic medical records. Interns anonymously completed a 15-question pre-test on topics covered in the boot camp as well as an identical post-test after the boot camp. The interns were surveyed regarding their confidence and satisfaction. Results Thirty-eight interns participated in the boot camp. Prior to the boot camp, few interns reported confidence managing common outpatient conditions. The average pre-test knowledge score was 46.3%. The average post-test knowledge score significantly improved to 76.1% (p<0.001). All interns reported that the boot camp was good preparation for clinics and 97% felt that the boot camp boosted their confidence. Conclusions The ambulatory boot camp pilot improved primary care knowledge, and interns thought it was good preparation for clinic. The ambulatory boot camp was well received and may be an effective way to improve the preparation of interns for primary care clinic. Further assessment of clinical performance and expansion to other programs and specialties should be considered.

Medical student resilience and stressful clinical events during clinical training

ABSTRACT Background: Medical students face numerous stressors during their clinical years, including difficult clinical events. Fostering resilience is a promising way to mitigate negative effects of stressors, prevent burnout, and help students thrive after difficult experiences. However, little is known about medical student resilience. Objective: To characterize medical student resilience and responses to difficult clinical events during clinical training. Design: Sixty-two third-year (MS3) and 55 fourth-year (MS4) University of Chicago medical students completed surveys in 2016 assessing resilience (Connor Davidson Resilience Scale, CD-RISC 10), symptoms of burnout, need for resilience training, and responses to difficult clinical events. Results: Medical student mean resilience was lower than in a general population sample. Resilience was higher in males, MS4s, those without burnout symptoms, and students who felt able to cope with difficult clinical events. When students experienced difficult events in the clinical setting, the majority identified poor team dynamics among the most stressful, and agreed their wellbeing was affected by difficult clinical events. A majority also would prefer to discuss these events with their team later that day. Students discussed events with peers more than with attendings or residents. Students comfortable discussing stress and burnout with peers had higher resilience. Most students believed resilience training would be helpful and most beneficial during MS3 year. Conclusions: Clinical medical student resilience was lower than in the general population but higher in MS4s and students reporting no burnout. Students had some insight into their resilience and most thought resilience training would be helpful. Students discussed difficult clinical events most often with peers. More curricula promoting medical student resilience are needed.

Faculty member feedback reports

Obtaining sufficient written feedback from faculty members on clerkship student evaluations is challenging. Few successful interventions, however, have been published on improving written feedback or evaluation content.

Transfer of Graduating Residents’ Continuity Practices

To the Editors:— We applaud Caines et al.1 for addressing an important patient safety topic, year-end resident continuity clinic handoffs, that has received little attention thus far.2 The high percentage of patients lost to follow-up is astounding, highlighting that clinic handoffs are a vulnerable time for patients. Because very few patients who were lost to follow-up were in fact scheduled for an appointment, it is critical to explore if more effective scheduling may improve this transition of care. In addition to more effective scheduling, we wondered if patient factors or patterns of care may explain why patients did not follow up. For instance, among the 29% of patients lost to follow-up because they did not keep their appointment, it would be important to understand whether these patients had a history of missing appointments. In other words, did they miss the appointment because of the handoff or because they tend to miss appointments? The distinction is important since patients who miss appointments generally may require even more intense follow-up and coaching during the handoff to overcome barriers to visiting their physician. Patients deemed to be high risk may also be more likely to be lost to follow-up in their resident clinic because they present elsewhere to emergency departments or hospitals for acute care. Therefore, understanding the acute care utilization patterns of these patients both before and after the handoff is important to consider for future studies. Lastly, defining high-priority patients as those requiring follow-up within 1 year may be too crude a measure given the chronic illness burden of resident clinic patients. It has previously been demonstrated that US residents take care of underserved populations who are at risk for poor outcomes.3 Moreover, guidelines recommend that patients with certain conditions, such as diabetes, should be seen every 3 months, making certain high-risk patients in need of more frequent care than once a year. Understanding what constitutes a high-risk patient given the increasing complexity of primary care and already high illness burden for resident clinic patients is critical. Rebalancing case loads after a year-end clinic handoff to ensure appropriate workloads and illness burden has been a strategy used in other disciplines.4

Initial Characterization of Internal Medicine Resident Resilience and Association with Stress and Burnout

Introduction. Burnout is prevalent in medical trainees. Little data exists on resident resilience. Methods. Anonymous surveys were provided to a convenience sample of internal medicine residents. Resilience was assessed using the Connor-Davidson resilience scale. Responses were categorized into low (<70), intermediate (70–79), and high (80–100) resilience. Results. 77 residents from six institutions completed surveys. 26% of residents had high resilience, 43% intermediate, and 31% low. The mean resilience score was and lower than the general population (mean , ). Trainees with high resilience were more likely to never have stress interfere with their relationships outside of work (high: 40%; low: 0%; ). High resilience residents were more likely to have the skills to manage stress and burnout (high: 80%; low: 46%; ) and less likely to feel inferior to peers (high: 20.0%; low: 70.8%; ). There was a trend towards those with high resilience reporting less burnout (high: 40.0%; intermediate: 27%; low: 16.7%; ). Only 60% report a program outlet to discuss burnout. Conclusions. There is a wide range of resilience among IM residents and scores were lower than the general population. Low resilience is associated with more stress interfering with relationships, feeling inferior to peers, and fewer skills to manage stress and burnout.

Resident Shift Handoff Strategies in US Internal Medicine Residency Programs.

Resident Shift Handoff Strategies in US Internal Medicine Residency Programs National organizations such as the Accreditation Council for Graduate Medical Education, Agency for Healthcare Research and Quality, and Joint Commission have recommended specific strategies to improve resident handoffs, such as dedicated time and space to perform handoffs, standardized templates, and supervision by senior physicians.1,2 How these best-practice recommendations are implemented across programs is unknown. Program directors are expected to standardize and improve handoffs within their institutions’ residency programs. Their perspective on strategies and satisfaction with this process can provide insight into improving handoffs. We describe implementation of recommended handoff strategies in a US cohort of internal medicine residency programs and association with program director satisfaction.

Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs

BackgroundWhile there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern.ObjectivesThe 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country.DesignNationwide survey.ParticipantsAll internal medicine program directors registered with APDIM.Main MeasuresDescriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs.Key ResultsOf the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year–End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff.ConclusionsMost internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.