Craig R. Keenan

Factors affecting resident performance: development of a theoretical model and a focused literature review.

Purpose The clinical performances of physicians have come under scrutiny as greater public attention is paid to the quality of health care. However, determinants of physician performance have not been well elucidated. The authors sought to develop a theoretical model of physician performance, and explored the literature about factors affecting resident performance. Method Using expert consensus panel, in 2002–03 the authors developed a hypothesis-generating model of resident performance. The developed model had three input factors (individual resident factors, health care infrastructure, and medical education infrastructure), intermediate process measures (knowledge, skills, attitudes, habits), and final health outcomes (affecting patient, community and population). The authors used factors from the model to focus a PubMed search (1967–2002) for all original articles related to the factors of individual resident performance. Results The authors found 52 original studies that examined factors of an individual residents performance. They describe each studys measurement instrument, study design, major findings, and limitations. Studies were categorized into five domains: learning styles/personality, social/financial factors, practice preferences, personal health, and response to job environment. Few studies examined intermediate or final performance outcomes. Most were single-institution, cross-sectional, and survey-based studies. Conclusions Attempting to understand resident performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding the individual patient and his or her environment. Based on a systematic review of the literature, the authors found few discrete associations between the factors of individual resident and the residents actual job performance. Additionally, they identify and discuss major gaps in the educational literature.

The Many Faces of Error Disclosure: A Common Set of Elements and a Definition

BackgroundPatients want to know when errors happen in their care. Professional associations, ethicists, and patient safety experts endorse disclosure of medical error to patients. Surveys of physicians show that they believe harmful errors should be disclosed to patients, yet errors are often not disclosed.ObjectiveTo understand the discrepancy between patients’ expectations and physicians’ behavior concerning error disclosure.Design, Setting, and ParticipantsWe conducted focus groups to determine what constitutes disclosure of medical error. Twenty focus groups, 4 at each of 5 academic centers, included 204 hospital administrators, physicians, residents, and nurses.ApproachQualitative analysis of the focus group transcripts with attention to examples of error disclosure by clinicians and hospital administrators.ResultsClinicians and administrators considered various forms of communication about errors to be error disclosure. Six elements of disclosure identified from focus group transcripts characterized disclosures ranging from Full disclosure (including admission of a mistake, discussion of the error, and a link from the error to harm) to Partial disclosures, which included deferral, misleading statements, and inadequate information to “connect the dots.” Descriptions involving nondisclosure of harmful errors were uncommon.ConclusionsError disclosure may mean different things to clinicians than it does to patients. The various forms of communication deemed error disclosure by clinicians may explain the discrepancy between error disclosure beliefs and behaviors. We suggest a definition of error disclosure to inform practical policies and interventions.

High risk for venous thromboembolism in diabetics with hyperosmolar state: comparison with other acute medical illnesses

Summary.  Background: Diabetes mellitus is generally not recognized as an important risk factor for venous thromboembolism (VTE). However, clinical observations and case reports have suggested that patients with diabetes and hyperosmolarity may be at increased risk for VTE. Objectives: To determine the risk of VTE in patients hospitalized for diabetes with hyperosmolar state compared to patients with other acute medical illnesses. Patients/methods: The California Patient Discharge Data Set was used to determine the incidence of first‐time VTE in all patients admitted between 1995 and 2000 for diabetes with hyperosmolarity and 11 other acute medical conditions. Proportional hazard modeling was used to adjust for age, race, gender, and prior hospitalization within 3 months. Results: Among 2859 patients with diabetes and hyperosmolarity, 34 (1.2%) developed VTE during the hospitalization and 14 (0.5%) developed VTE within 91 days after discharge. In an adjusted multivariate model comparing the risk of VTE to cases with depression, patients with hyperosmolarity had a significantly higher risk of VTE [hazard ratio (HR) = 16.3; 95% confidence interval (CI): 10–25] comparable to the risk associated with sepsis (HR = 19.3; 95% CI: 13–29) or acute connective tissue disease (HR = 21; 95% CI: 15–31). Compared to uncomplicated diabetes, patients with hyperosmolarity had a significantly higher risk of VTE (HR = 3.0; 95% CI: 2.1–4.5) whereas patients with ketoacidosis were not at higher risk (HR = 1.2; 95% CI: 0.8–1.7). Conclusions: Patients hospitalized for diabetes with hyperosmolarity are at increased risk for developing VTE both during their inpatient stay and in the 3 months after discharge. Thromboprophylaxis in these patients appears warranted, and extended prophylaxis for after hospital discharge should be studied.

Faculty development to enhance humanistic teaching and role modeling: a collaborative study at eight institutions.

BackgroundThere is increased emphasis on practicing humanism in medicine but explicit methods for faculty development in humanism are rare.ObjectiveWe sought to demonstrate improved faculty teaching and role modeling of humanistic and professional values by participants in a multi-institutional faculty development program as rated by their learners in clinical settings compared to contemporaneous controls.DesignBlinded learners in clinical settings rated their clinical teachers, either participants or controls, on the previously validated 10-item Humanistic Teaching Practices Effectiveness (HTPE) questionnaire.ParticipantsGroups of 7-9 participants at 8 academic medical centers completed an 18-month faculty development program. Participating faculty were chosen by program facilitators at each institution on the basis of being promising teachers, willing to participate in the longitudinal faculty development program.InterventionOur 18-month curriculum combined experiential learning of teaching skills with critical reflection using appreciative inquiry narratives about their experiences as teachers and other reflective discussions.Main MeasuresThe main outcome was the aggregate score of the ten items on the questionnaire at all institutions.Key ResultsThe aggregate score favored participants over controls (P = 0.019) independently of gender, experience on faculty, specialty area, and/or overall teaching skills.ConclusionsLongitudinal, intensive faculty development that employs experiential learning and critical reflection likely enhances humanistic teaching and role modeling. Almost all participants completed the program. Results are generalizable to other schools.

An academic-community partnership to improve care for the underserved.

Despite the need for a robust primary care workforce, the number of students and residents choosing general internal medicine careers continues to decline. In this article, the authors describe their efforts at the University of California, Davis School of Medicine to bolster interest in internal medicine careers and improve the quality of care for medically underserved populations through a tailored third-year residency track developed in partnership with the Sacramento County Department of Health and Human Services. The Transforming Education and Community Health (TEACH) Program improves continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares residents to provide coordinated care for vulnerable populations. Since its inception in 2005, 25 residents have graduated from the TEACH Program. Compared with national rates, TEACH graduates are more likely to practice general internal medicine and to practice in medically underserved settings. TEACH residents report high job satisfaction and provide equal or higher-quality diabetes care than that indicated by national benchmarks. The authors provide an overview of the TEACH Program, including curriculum details, preliminary outcomes, barriers to continued and expanded implementation, and thoughts about the future of the program.

Age as a risk factor for venous thromboembolism after major surgery

Purpose of review Postoperative deep venous thrombosis and pulmonary embolism are serious and potentially life-threatening complications that frequently occur after major surgery. Most guidelines for thromboprophylaxis use advancing age as a key component to estimate thromboembolic risk. The reported effect of age on postoperative venous thromboembolism varies widely, making it unclear whether age alone is a significant risk factor. This article reviews the recent literature on the effect of age on the incidence of postoperative venous thromboembolism. Recent findings Between 2003 and 2005, several cohort studies assessed the risk factors for postoperative venous thromboembolism, showing a variable effect of age on its incidence in the 2- to 3-month period after major surgery. Studies also revealed a significant difference in the effect of age on the incidence of venous thromboembolism depending on the type of surgery. Obesity, postoperative immobilization, the use of thromboprophylaxis, the nature of the surgery, and underlying comorbid conditions such as heart failure seem to have a greater influence on the risk of venous thromboembolism than does age. Summary The variation in the effect of age on postoperative venous thromboembolism likely depends on whether or not other comorbid conditions or age-related changes in functional status are considered as risk factors. When these other risk factors are taken into account, the effect of advanced age decreases. More research is needed to develop validated venous thromboembolism risk-prediction tools for specific types of surgery. By use of this information, the intensity and duration of postoperative thromboprophylaxis can be tailored to the level of risk, not just age alone.

A 43-Year-Old Woman with Abdominal Pain and Fever

In this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion.

Introducing Exercises in Clinical Reasoning

Clinical reasoning is a quintessential skill of the internist, the cornerstone of safe, effective medical care. While new technologies and accumulating evidence continue to change practice, they supplement rather than supplant clinical judgment in the care of the individual patient. Multiple studies show that transparency and instruction in clinical reasoning are what trainees seek most from their attending physicians. And while we know good reasoning when we see it, we often have difficulty describing it in specific terms. With this issue, JGIM introduces readers to the lexicon of clinical reasoning with a new feature called Exercises in Clinical Reasoning. These exercises build on the successful format of other series that intersperse iterative case presentations with extemporaneous expert clinician commentary. We allow the reader to follow along as an experienced clinician approaches an unknown, challenging patient care dilemma. But we add another layer of commentary that peers into the clinician’s mind (as much as we can) to highlight the normal, insightful, and sometimes errant judgment displayed in attempting to solve each case. We hope that this running diagnostic reasoning commentary and concluding discussion will help our readers become more facile with the science of clinical reasoning, enabling them to become more cognizant of their own judgments and more effectively teach reasoning skills to others. In this issue, “Doing What Comes Naturally” begins the Exercises with a relatively straightforward case involving a common clinical problem (hypertension) to introduce basic clinical reasoning concepts. In upcoming issues we hope to present cases with more twists, turns, blind alleys, or errors that highlight the more nuanced aspects of clinical reasoning. We invite clinicians to submit their interesting cases and to provide any suggestions or critiques on this new series.

The Elusive SIRS Diagnosis

In this series, a clinician extemporaneously discusses a diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process by a clinician educator (italics) is integrated throughout the discussion.

Assessing faculty attitudes after participation in an interprofessional teaching scholars programme

ABSTRACT Promoting interprofessional education (IPE) and practice is a priority in academic health centres; however, implementation of IPE can be challenging. Recognizing the need for faculty development in teaching, and specifically IPE, the University of California, Davis Schools of Health launched the Interprofessional Teaching Scholars Program (ITSP) in 2014. Two cohorts of 11 faculty scholars each completed the nine-month programme and participated in this longitudinal comparative study in which pre- and post-assessments using a validated survey instrument were administered to measure changes in faculty attitudes towards IPE and collaborative practice. There was a statistically significant increase in the summated scores on all three of the subscales: Attitudes Towards Interprofessional Health Care Teams, Attitudes Towards IPE, and Attitudes Towards Interprofessional Learning in the Academic Setting. The results suggest that the ITSP was associated with positive changes in faculty attitudes related to interprofessional collaboration and teamwork.