Carol K. Bates

Electronic Medical Record Reminders and Panel Management to Improve Primary Care of Elderly Patients

BACKGROUND Most elderly patients do not receive recommended preventive care, acute care, and care for chronic conditions. METHODS We conducted a controlled trial to assess the effectiveness of electronic medical record (EMR) reminders, with or without panel management, on health care proxy designation, osteoporosis screening, and influenza and pneumococcal vaccinations in patients older than 65 years. Physicians were assigned to 1 of the following 3 arms: EMR reminder, EMR reminder plus panel manager, or control. We assessed completion of recommended practices during a 1-year period. RESULTS Among patients who had not already received the recommended care, health care proxy was designated in 6.5% of patients in the control arm, 8.8% of the EMR reminder arm, and 19.7% of the EMR reminder plus panel manager arm (P=.002). Bone density screening was completed in 17.7% of patients in the control arm, 19.7% of the EMR reminder arm, and 30.5% of the EMR reminder plus panel manager arm (P=.02). Pneumococcal vaccine was given to 13.1% of patients in the control arm, 19.5% of the EMR reminder arm, and 25.6% of the EMR reminder plus panel manager arm (P=.02). Influenza vaccine was given to 46.8% of patients in the control arm, 56.5% of the EMR reminder arm, and 59.7% of the EMR reminder plus panel manager arm (P=.002). Results were similar when adjusted for individual physician performance in the preceding year, patient age, patient sex, years cared for by the practice, and number of visits. CONCLUSIONS Electronic medical record reminders alone facilitated improvement in vaccination rates and, when augmented by panel management, facilitated further improvement in vaccination rates and boosted the rates of health care proxy designation and bone density screening. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01313169.

Ambulatory-Based Education in Internal Medicine: Current Organization and Implications for Transformation. Results of A National Survey of Resident Continuity Clinic Directors

BACKGROUNDMany have called for ambulatory training redesign in internal medicine (IM) residencies to increase primary care career outcomes. Many believe dysfunctional, clinic environments are a key barrier to meaningful ambulatory education, but little is actually known about the educational milieu of continuity clinics nationwide.OBJECTIVEWe wished to describe the infrastructure and educational milieu at resident continuity clinics and assess clinic readiness to meet new IM-RRC requirements.DESIGNNational survey of ACGME accredited IM training programs.PARTICIPANTSDirectors of academic and community-based continuity clinics.RESULTSTwo hundred and twenty-one out of 365 (62%) of clinic directors representing 49% of training programs responded. Wide variation amongst continuity clinics in size, structure and educational organization exist. Clinics below the 25th percentile of total clinic sessions would not meet RRC-IM requirements for total number of clinic sessions. Only two thirds of clinics provided a longitudinal mentor. Forty-three percent of directors reported their trainees felt stressed in the clinic environment and 25% of clinic directors felt overwhelmed.LIMITATIONSThe survey used self reported data and was not anonymous. A slight predominance of larger clinics and university based clinics responded. Data may not reflect changes to programs made since 2008.CONCLUSIONSThis national survey demonstrates that the continuity clinic experience varies widely across IM programs, with many sites not yet meeting new ACGME requirements. The combination of disadvantaged and ill patients with inadequately resourced clinics, stressed residents, and clinic directors suggests that many sites need substantial reorganization and institutional commitment.New paradigms, encouraged by ACGME requirement changes such as increased separation of inpatient and outpatient duties are needed to improve the continuity clinic experience.

The Challenging Pelvic Examination

While there is a large body of evidence on the effectiveness of Pap smears for cervical cancer screening and on screening for cervical gonorrhea and Chlamydia, there is sparse evidence to support other portions of the pelvic examination and little guidance on examination logistics. Maximizing comfort should be the goal; lubrication use and careful speculum selection and insertion can ease this intrusive procedure. This is particularly important in adolescent and menopausal women, sexual minorities, obese women, women with disabilities, and women with a history of trauma or prior instrumentation affecting the genitalia. We review the evidence and provide guidance to minimize physical and psychological discomfort with pelvic examination.

The Revolving Door of Resident Continuity Practice: Identifying Gaps in Transitions of Care

BackgroundIt is well documented that transitions of care pose a risk to patient safety. Every year, graduating residents transfer their patient panels to incoming interns, yet in our practice we consistently find that approximately 50% of patients do not return for follow-up care within a year of their resident leaving.ObjectiveTo examine the implications of this lapse of care with respect to chronic disease management, follow-up of abnormal test results, and adherence with routine health care maintenance.DesignRetrospective chart reviewSubjectsWe studied a subset of patients cared for by 46 senior internal medicine residents who graduated in the spring of 2008. 300 patients had been identified as high priority requiring follow-up within a year. We examined the records of the 130 of these patients who did not return for care.Main MeasuresWe tabulated unaddressed abnormal test results, missed health care screening opportunities and unmonitored chronic medical conditions. We also attempted to call these patients to identify barriers to follow-up.Key ResultsThese patients had a total of 185 chronic medical conditions. They missed a total of 106 screening opportunities including mammogram (24), Pap smear (60) and colon cancer screening (22). Thirty-two abnormal pathology, imaging and laboratory test results were not followed-up as the graduating senior intended. Among a small sample of patients who were reached by phone, barriers to follow-up included a lack of knowledge about the need to see a physician, distance between home and our office, difficulties with insurance, and transportation.ConclusionsThis study demonstrates the high-risk nature of patient handoffs in the ambulatory setting when residents graduate. We discuss changes that might improve the panel transfer process.

Succeeding as a Clinician Educator: Useful Tips and Resources

Clinician Educators (CEs) play an essential role in the education and patient care missions of academic medical centers. Despite their crucial role, academic advancement is slower for CEs than for other faculty. Increased clinical productivity demands and financial stressors at academic medical centers add to the existing challenges faced by CEs. This perspective seeks to provide a framework for junior CEs to consider with the goal of maximizing their chance of academic success. We discuss six action areas that we consider central to flourishing at academic medical centers: 1. Clarify what success means and define goals; 2. Seek mentorship and be a responsible mentee; 3. Develop a niche and engage in relevant professional development; 4. Network; 5. Transform educational activities into scholarship; and 6. Seek funding and other resources.

Striving for gender equity in academic medicine careers: A call to action

Women represent approximately half of students entering medical schools and more than half of those entering PhD programs. When advancing through the academic and professional fields, however, women continually face barriers that men do not. In this Commentary, the authors offer ideas for coordinating the efforts of organizations, academic institutions, and leaders throughout the scientific and medical professions to reduce barriers that result in inequities and, instead, strive for gender parity. Specific areas of focus outlined by the authors include facilitating women’s access to formal and informal professional networks, acknowledging and addressing the gender pay gap as well as the lack of research funding awarded to women in the field, and updating workplace policies that have not evolved to accommodate women’s lifestyles. As academic institutions seek access to top talent and the means to develop those individuals capable of generating the change medicine and science needs, the authors urge leaders and change agents within academic medicine to address the systemic barriers to gender equity that impede us from achieving the mission to improve the health of all.

A Review of the Medical Education Literature for Graduate Medical Education Teachers

BACKGROUND A rapidly evolving body of literature in medical education can impact the practice of clinical educators in graduate medical education. OBJECTIVE To aggregate studies published in the medical education literature in 2011 to provide teachers in general internal medicine with an overview of the current, relevant medical education literature. REVIEW We systematically searched major medical education journals and the general clinical literature for medical education studies with sound design and relevance to the educational practice of graduate medical education teachers. We chose 12 studies, grouped into themes, using a consensus method, and critiqued these studies. RESULTS Four themes emerged. They encompass (1) learner assessment, (2) duty hour limits and teaching in the inpatient setting, (3) innovations in teaching, and (4) learner distress. With each article we also present recommendations for how readers may use them as resources to update their clinical teaching. While we sought to identify the studies with the highest quality and greatest relevance to educators, limitation of the studies selected include their single-site and small sample nature, and the frequent lack of objective measures of outcomes. These limitations are shared with the larger body of medical education literature. CONCLUSIONS The themes and the recommendations for how to incorporate this information into clinical teaching have the potential to inform the educational practice of general internist educators as well as that of teachers in other specialties.

Update in medical education.

Academic general internists are integral medical educators across the entire continuum of learners. Medical education research allows us to incorporate best practices in curriculum development and assessment and to promote effective teaching behaviors. In this paper, we summarize selected articles chosen for presentation at the Update in Medical Education session at the 30th annual meeting of the Society of General Internal Medicine.

Are we making progress in medical education

Scholarship in medical education consists of a rich compilation of studies and innovations designed to enhance our understanding of the process and content of education, contributing to and enhancing the training of physicians and their practice of high-quality patient care. Viewed through the lens of the Society of General Internal Medicine (SGIM) Residency Reform Task Force Report,1 the 29 reports in this issue advance our understanding of the educational mission and vision for a broad range of topics.

Update in medical education 2010-2011.

This review brings important medical education articles of 2010 to the attention of academic general internists. These studies offer methods to improve trainee supervision, continuity of care and the physical examination. The summaries also serve as a reminder of the environmental challenges facing faculty and learners, including burnout and a sense of entitlement among learners, and offer some insight in addressing both issues.