Ann H. Cottingham

Enhancing the Informal Curriculum of a Medical School: A Case Study in Organizational Culture Change

BackgroundCalls for organizational culture change are audible in many health care discourses today, including those focused on medical education, patient safety, service quality, and translational research. In spite of many efforts, traditional “top–down” approaches to changing culture and relational patterns in organizations often disappoint.ObjectiveIn an effort to better align our informal curriculum with our formal competency-based curriculum, Indiana University School of Medicine (IUSM) initiated a school-wide culture change project using an alternative, participatory approach that built on the interests, strengths, and values of IUSM individuals and microsystems.ApproachEmploying a strategy of “emergent design,” we began by gathering and presenting stories of IUSM’s culture at its best to foster mindfulness of positive relational patterns already present in the IUSM environment. We then tracked and supported new initiatives stimulated by dissemination of the stories.ResultsThe vision of a new IUSM culture combined with the initial narrative intervention have prompted significant unanticipated shifts in ordinary activities and behavior, including a redesigned admissions process, new relational practices at faculty meetings, student-initiated publications, and modifications of major administrative projects such as department chair performance reviews and mission-based management. Students’ satisfaction with their educational experience rose sharply from historical patterns, and reflective narratives describe significant changes in the work and learning environment.ConclusionsThis case study of emergent change in a medical school’s informal curriculum illustrates the efficacy of novel approaches to organizational development. Large-scale change can be promoted with an emergent, non-prescriptive strategy, an appreciative perspective, and focused and sustained attention to everyday relational patterns.Calls for organizational culture change are audible in many health care discourses today, including those focused on medical education, patient safety, service quality, and translational research. In spite of many efforts, traditional “top–down” approaches to changing culture and relational patterns in organizations often disappoint. In an effort to better align our informal curriculum with our formal competency-based curriculum, Indiana University School of Medicine (IUSM) initiated a school-wide culture change project using an alternative, participatory approach that built on the interests, strengths, and values of IUSM individuals and microsystems. Employing a strategy of “emergent design,” we began by gathering and presenting stories of IUSM’s culture at its best to foster mindfulness of positive relational patterns already present in the IUSM environment. We then tracked and supported new initiatives stimulated by dissemination of the stories. The vision of a new IUSM culture combined with the initial narrative intervention have prompted significant unanticipated shifts in ordinary activities and behavior, including a redesigned admissions process, new relational practices at faculty meetings, student-initiated publications, and modifications of major administrative projects such as department chair performance reviews and mission-based management. Students’ satisfaction with their educational experience rose sharply from historical patterns, and reflective narratives describe significant changes in the work and learning environment. This case study of emergent change in a medical school’s informal curriculum illustrates the efficacy of novel approaches to organizational development. Large-scale change can be promoted with an emergent, non-prescriptive strategy, an appreciative perspective, and focused and sustained attention to everyday relational patterns.

New Workforce Development in Dementia Care: Screening for “Caring”: Preliminary Data

The United States has a significant shortage of trained geriatricians and of nurses, social workers, and paraprofessionals educated to care for elderly adults. As the aging population continues to grow, providing high‐quality care will require new models that better address the many needs of aging individuals and their caregivers, using cost‐effective strategies. Responding to this need, the Indiana University Center for Aging Research implementation scientists developed, tested, and are now scaling up a successful collaborative care coordination model for older adults with dementia, depression, or both: the Aging Brain Care program. This model now includes a newly created frontline care provider position, the Care Coordinator Assistant. The Care Coordinator Assistant works with individuals and caregivers to monitor biopsychosocial needs and deliver evidence‐based and individualized care protocols, with close supervision from the registered nurse Care Coordinator. Recognizing that current hiring practices for frontline providers were insufficient to screen for critical abilities expected in this new position, including the ability to express “caring” and empathy, a new screening process was created building on the Multiple Mini Interview (MMI) format. The Care Coordinator Assistant MMI comprised six stations, each created to simulate challenging scenarios that will be frequently encountered and to assess important candidate abilities. Overall, the six‐station MMI, with two to three items per station, provided factorially valid measures and good predictive ability. The process did not appear to be overly burdensome for candidates, and interviewers noted that it was helpful in discriminating between candidates.

Exploring the Meaning of Respect in Medical Student Education: an Analysis of Student Narratives

ABSTRACTBACKGROUNDRespect for others is recognized in the medical literature and society as an essential attribute of the good medical professional. However, the specific meaning of respect varies widely and is underexplored as a lived experience of physicians-in-training.OBJECTIVETo describe third-year medical students’ narratives of respect and disrespect [(dis)respect] during their internal medicine clerkship.DESIGNQualitative thematic analysis of 152 third-year student narratives that ‘taught them something about professionalism,’ focusing on (dis)respect.APPROACHImmersion/crystallization narrative analysis.RESULTSWe reviewed 595 professionalism narratives and found that one in four narratives involved (dis)respect. We then found that 2/3 of these narratives were negative (describing instances of disrespect rather than respect). In the other coded categories, the proportion of negative narratives was significantly lower. In order to better understand these results, we analyzed the content of the (dis)respect narratives and identified six primary themes: (1) content and manner of communication (including, appreciating or belittling, being sensitive or blunt and respecting privacy); (2) conduct: behaviors expressing (dis)respect; (3) patient centeredness: honoring others’ preferences, decisions and needs; (4) treating others as equals; (5) valuing the other and their experience and/or problem; and (6) nurturing students’ learning.CONCLUSIONSFocusing on the lived experience of (dis)respect on wards broadens the concept of respect beyond any one type of act, behavior or attitude. Students perceive respect as a way of being that applies in all settings (private and public), with all participants (patients, family members, nurses, colleagues and students) and under all circumstances (valuing others’ time, needs, preferences, choices, opinions and privacy). Respect seems to entail responding to a need, while disrespect involves ignoring the need or bluntly violating it.

Impact of Community Health Workers on Elderly Patients’ Advance Care Planning and Health Care Utilization: Moving the Dial

Background: Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences. Objective: To evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment. Research Design: A year-long, pre-post intervention using lay community health workers [care coordinator assistants (CCAs)] trained to conduct and document ACP conversations with patients during home health visits with pre-post evaluation. Subjects: The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% white. Measures: Documentation of ACP conversation in electronic health record fields and health care utilization outcomes. Results: In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least 1 discussion about ACP in the electronic health record. In the 1-year preintervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (hazard ratios, 0.66; 95% confidence interval, 0.45–0.97), and similar effects are apparent on ED use independent of age and prior ED use effects. Conclusions: Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations.

Teaching caring attitudes.

No abstract available.

Medical Students' Professionalism Narratives Reveal That Experiences With Death, Dying, or Palliative Care Are More Positive Than Other Experiences During Their Internal Medicine Clerkship.

Purpose: More physicians need to acquire the skills of primary palliative care. Medical students’ clerkship experiences with death, dying, and palliative care (DDPC), however, may create barriers to learning such skills during residency. Whether professional development is differentially affected by DDPC is unknown. This knowledge gap potentially hinders the development of educational strategies to optimize students’ preparedness for primary palliative care. Method: Third-year students submitted professionalism narratives (N = 4062) during their internal medicine clerkship between 2004 and 2011. We identified DDPC-related narratives and then randomly selected control narratives. Narratives were compared by valence (positive or negative) and professionalism-related themes. Results and Conclusion: Less than 10% of the narratives were related to DDPC, but the majority was positive. There was a significant overlap in professionalism themes between DDPC and control narratives. The results suggest student preparedness for primary palliative care may be improved by addressing the common professionalism challenges of clinical clerkships.

Clarifying Values and Preferences for Care Near the End of Life: The Role of a New Lay Workforce

Community health workers (CHWs) can engage elderly persons in advance care planning (ACP) conversations. We report how trained CHWs used Go Wish cards (GWR cards) to identify patients’ highest priority preferences and evaluated whether engaging in ACP conversations was associated with subsequent health care utilization. A one-year long, pre-post longitudinal design was used to evaluate our educational intervention using mixed-methods. 392 patients (mean of 73.3 years, 82% women, 48% African American, 43% Caucasian) enrolled in the Aging Brain Care (ABC) program and participated in ACP discussions with CHWs. We expanded the role of the ABC’s CHW, who work directly with individuals and caregivers during home visits to monitor bio-psycho-social needs, to include ACP conversations. The CHWs received ACP training, practice with tools such as GWR cards, and support from an electronic health record (EHR) clinical decision support tool. Quantitative measures of patients’ ACP preferences and health care utilization were abstracted from the EHR. Qualitative data about patients’ perceptions of CHWs in facilitating ACP discussions was obtained through semi-structured interviews. Eighty-six patients’ data indicated that they had engaged in a preferences-for-care process using GWR cards. The top-three card choices by patients was attending to spirituality and religious concerns, preparing for end of life, and maintaining personal wholeness. CHWs were able to effectively engage in ACP conversations with patients and GWR cards were a positive way to stimulate discussion of issues previously undiscussed.

Response to depression treatment in the Aging Brain Care Medical Home model

Objective To evaluate the effect of the Aging Brain Care (ABC) Medical Home program’s depression module on patients’ depression severity measurement over time. Design Retrospective chart review. Setting Public hospital system. Participants Patients enrolled in the ABC Medical Home program between October 1, 2012 and March 31, 2014. Methods The response of 773 enrolled patients who had multiple patient health questionnaire-9 (PHQ-9) scores recorded in the ABC Medical Home program’s depression care protocol was evaluated. Repeatedly measured PHQ-9 change scores were the dependent variables in the mixed effects models, and demographic and comorbid medical conditions were tested as potential independent variables while including random effects for time and intercept. Results Among those patients with baseline PHQ-9 scores >10, there was a significant decrease in PHQ-9 scores over time (P<0.001); however, the effect differed by gender (P=0.015). On average, women’s scores (4.5 point drop at 1 month) improved faster than men’s scores (1 point drop at 1 month). Moreover, both men and women had a predicted drop of 7 points (>50% decline from baseline) on the PHQ-9 at 6 months. Conclusion These analyses demonstrate evidence for the sustained effectiveness of the ABC Medical Home program at inducing depression remission outcomes while employing clinical staff who required less formal training than earlier clinical trials.

Evaluation of interprofessional relational coordination and patients’ perception of care in outpatient oncology teams

ABSTRACT This pilot study was designed to measure teamwork and the relationship of teamwork to patient perceptions of care among 63 members of 12 oncology teams at a Cancer Centre in the Midwest. Lack of teamwork in cancer care can result in serious clinical errors, fragmentation of care, and poor quality of care. Many oncology team members, highly skilled in clinical care, are not trained to work effectively as members of a care team. The research team administered the Relational Coordination survey to core oncology team members—medical oncologists, nurse coordinators, and clinical secretaries—to measure seven dimensions of team skills (four relating to communication [frequency, timeliness, accuracy, and problem solving] and three relating to relationship [shared goals, shared knowledge, and mutual respect]) averaged to create a Relational Coordination Index. The results indicated that among the team member roles, nurse coordinator relational coordination indices were the strongest and most positively correlated with patient perception of care. Statistically significant correlations were intra-nurse coordinator relational coordination indices and two patient perception of care factors (information and education and patient’s preferences). All other nurse coordinator intra-role as well as inter-role correlations were also positively correlated, although not statistically significant.

Physicians in Postgraduate Training Characteristics and Support of Palliative Sedation for Existential Distress

Introduction: Palliative sedation for refractory existential distress (PS-ED) is ethically troubling but potentially critical to quality end-of-life (EOL) care. Physicians’ in postgraduate training support toward PS-ED is unknown nor is it known how empathy, hope, optimism, or intrinsic religious motivation (IRM) affect their support. These knowledge gaps hinder efforts to support physicians who struggle with patients’ EOL care preferences. Methods: One hundred thirty-four postgraduate physicians rated their support of PS for refractory physical pain (PS-PP) or PS-ED, ranked the importance of patient preferences in ethically challenging situations, and completed measures of empathy, hope, optimism, and IRM. Predictors of PS-ED and PS-PP support were examined using binary and multinomial logistic regression. Results: Only 22.7% of residents were very supportive of PS-ED, and 82.0% were very supportive of PS-PP. Support for PS-PP or PS-ED did not correlate with levels of empathy, hope, optimism, or IRM; however, for residents with lower IRM, greater optimism was associated with greater PS-ED support. In contrast, among residents with higher IRM, optimism was not associated with PS-ED support. Conclusions: Comparing current results to published surveys, a similar proportion of residents and practicing physicians support PS-ED and PS-PP. In contrast to practicing physicians, however, IRM does not directly influence residents’ supportiveness. The interaction between optimism and IRM suggests residents’ beliefs and characteristics are salient to their EOL decisions. End-of-life curricula should provide physicians opportunities to reflect on the personal and ethical factors that influence their support for PS-ED.