Anna Chang

Transforming Primary Care Training—Patient-Centered Medical Home Entrustable Professional Activities for Internal Medicine Residents

ABSTRACTINTRODUCTIONThe U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice.AIMWe address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs?PROGRAM DESCRIPTIONThe 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, ‘medical home builder’ tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs).RESULTSThe competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs.DISCUSSIONThe list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Length of Stay for Older Adults Residing in Nursing Homes at the End of Life

OBJECTIVES: To describe lengths of stay of nursing home decedents.

Behavior change counseling curricula for medical trainees: A systematic review

Purpose Unhealthy behaviors contribute to half of U.S. deaths. However, physicians lack sufficient skill in counseling patients to change behaviors. Characterizing effective published curricular interventions for behavior change counseling for medical trainees would inform educators toward improved training. Method The authors conducted a systematic literature search of studies published between 1965 and 2011 evaluating curricula on behavior change counseling for medical trainees. Included studies described behavior change counseling, teaching interventions for medical trainees, and assessment of interventions. The authors extracted eligible articles, rated outcomes for learners and patients using Kirkpatrick’s hierarchy, and determined study quality. Results Of 2,788 identified citations, 109 met inclusion criteria. Most studies were performed in the United States (98), 93 at a single institution, and 81 in primary care settings. Curricular topics for counseling included smoking (67 studies), nutrition (30), alcohol/drug use (26), and exercise (22). Although most studies did not include theoretical frameworks, 39 used the Transtheoretical Model of Change. Sixty-two studies involved eight or fewer hours of curricular time, and 51 spanned four or fewer weeks. The studies with highest-level outcomes and quality employed multiple curricular techniques and included practice of counseling techniques in either simulated or actual clinical settings. Conclusions Existing literature suggests that trainees learn behavior change counseling through active, realistic practice and implementation of reminder and feedback systems within actual clinical practice settings. Multiinstitutional medical education research on methods of teaching behavior change counseling that influence patients’ health outcomes are needed to ensure trainees’ clinical competence and improve patient care.

Impact of Cognitive Impairment on Screening Mammography Use in Older US Women

OBJECTIVES We evaluated mammography rates for cognitively impaired women in the context of their life expectancies, given that guidelines do not recommend screening mammography in women with limited life expectancies because harms outweigh benefits. METHODS We evaluated Medicare claims for women aged 70 years or older from the 2002 wave of the Health and Retirement Study to determine which women had screening mammography. We calculated population-based estimates of 2-year screening mammography prevalence and 4-year survival by cognitive status and age. RESULTS Women with severe cognitive impairment had lower rates of mammography (18%) compared with women with normal cognition (45%). Nationally, an estimated 120,000 screening mammograms were performed among women with severe cognitive impairment despite this groups median survival of 3.3 years (95% confidence interval = 2.8, 3.7). Cognitively impaired women who had high net worth and were married had screening rates approaching 50%. CONCLUSIONS Although severe cognitive impairment is associated with lower screening mammography rates, certain subgroups with cognitive impairment are often screened despite lack of probable benefit. Given the limited life expectancy of women with severe cognitive impairment, guidelines should explicitly recommend against screening these women.

Predicting failing performance on a standardized patient clinical performance examination: the importance of communication and professionalism skills deficits.

Background The purpose is to determine which assessment measures identify medical students at risk of failing a clinical performance examination (CPX). Method Retrospective case-control, multiyear design, contingency table analysis, n = 149. Results We identified two predictors of CPX failure in patient–physician interaction skills: low clerkship ratings (odds ratio 1.79, P = .008) and student progress review for communication or professionalism concerns (odds ratio 2.64, P = .002). No assessments predicted CPX failure in clinical skills. Conclusions Performance concerns in communication and professionalism identify students at risk of failing the patient–physician interaction portion of a CPX. This correlation suggests that both faculty and standardized patients can detect noncognitive traits predictive of failing performance. Early identification of these students may allow for development of a structured supplemental curriculum with increased opportunities for practice and feedback. The lack of predictors in the clinical skills portion suggests limited faculty observation or feedback.

Clinical skills-related learning goals of senior medical students after performance feedback

Medical Education 2011: 45: 878–885

Standardized patient-narrated web-based learning modules improve students' communication skills on a high-stakes clinical skills examination.

BACKGROUNDUse of web-based standardized patient (SP) modules is associated with improved medical student history-taking and physical examination skills on clinical performance examinations (CPX), but a benefit for communication skills has not been shown.AIMWe describe an innovative web-based SP module using detailed SP and faculty commentary to teach communication skills.SETTINGA public medical school in 2008–2009.PARTICIPANTSFourth-year medical students.PROGRAM DESCRIPTIONA 90-minute web-based module with three simulated clinical encounters was narrated by an expert clinician and SP to explain expected history-taking, physical examination, and communication skills behaviors. All 147 students were encouraged to review the module one month before the CPX.PROGRAM EVALUATIONOne hundred and six students (72%) viewed the web-based module. Students who watched the module performed significantly higher on the CPX communication score (+2.67%, p < 0.01) and overall score (+2.12%, p = 0.03), even after controlling for USMLE Step 1 and clerkship summary ratings. Use of the module did not significantly affect history/physical examination scores (+1.89%, p = 0.12).DISCUSSIONStudents who watched an optional web-based SP module prior to the CPX performed higher than those who did not on communication skills. The web-based module appears to be an effective CPX preparatory activity to enhance communication performance.

Complexity in Graduate Medical Education: A Collaborative Education Agenda for Internal Medicine and Geriatric Medicine

ABSTRACTInternal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.

EFFECTS OF LONGITUDINAL SMALL-GROUP LEARNING ON DELIVERY AND RECEIPT OF COMMUNICATION SKILLS FEEDBACK

Although feedback is a critical component of learning, recent data suggest that learners may discount feedback they receive. The emotional threat inherent in feedback can contribute to its ineffectiveness, particularly for sensitive topics like communication skills. Longitudinal relationships among peers may increase their sense of safety and soften the perceived threat of feedback to allow students to give, receive and potentially more effectively incorporate feedback. We studied the effects of prior shared learning experiences among medical students in the delivery and receipt of feedback on clinical (communication) skills.

Clinical skills remedial training for medical students.

hands-on sessions, followed by real and virtual group discussions and post-workshop assignments. After initial exposure, three of the eight trained faculty members chose to prepare OITs in their own subject areas. Two faculty members collaborated to produce a video on the dental procedure of inferior alveolar nerve block (IANB). The third faculty member produced study materials and an examination on hand hygiene for nursing students. Both OITs were produced within 3 months and were subject to peer review. The OITs were validated for pedagogical content and construct utility, levels of realism, and the interest and enthusiasm they generated among students. Evaluation of results and impact Of 116 nursing students tested after taking the OIT course on hand hygiene, 68 (59%) passed. Three of 15 students (20%) who received only face-to-face teaching passed. All students belonged to the same class. Nursing students were asked to give feedback on the OITs using a 5-point Likert scale. Respondents gave mean scores of 4.42 for ‘helped in real practice’ and 4.43 for ‘helped to understand the information better’. The data suggest the intervention attained the second level (learning) of Kirkpatrick’s four-level evaluation model. Initially, 29 dental students were given a lecture on IANB, followed by a live demonstration. Students then viewed the OIT. Students were tested about IANB after the lecture, again after the demonstration and finally after the OIT. Mean test scores at the three time-points were 50%, 70% and 90%, respectively. A total of 24 of 29 (83%) students said the OIT allowed for better visualisation of the IANB needle insertion and that the OIT enabled better understanding of the IANB procedure. The data suggest this intervention also attained Kirkpatrick’s second level of learning. Using HCI and ICT to develop and implement OITs can help to overcome both time and staffing shortages and improve medical student learning. The successful development and implementation of OITs can motivate faculty to develop further OITs. This sort of building of awareness and empowerment of faculty to build effective OITs can be replicated in other medical, nursing and dental schools to increase student learning.