Elizabeth Bernabeo

Opening the black box of clinical skills assessment via observation: a conceptual model

Medical Education 2011: 45: 1048–1060

Faculty staff perceptions of feedback to residents after direct observation of clinical skills.

Medical Education 2012: 46 : 201–215

Patients, Providers, And Systems Need To Acquire A Specific Set Of Competencies To Achieve Truly Patient-Centered Care

Studies show that patients want to be more involved in their own health care. Yet insufficient attention has been paid to the specific competencies of both patients and providers that are needed to optimize such patient engagement and shared decision making. In this article we address the knowledge, skills, and attitudes that patients, physicians, and health care systems require to effectively engage patients in their health care. For example, many patient-physician interactions still follow the traditional office visit format, in which the patient is passive, trusting, and compliant. We recommend imaginative models for redesigned office care, restructured reimbursement schemes, and increased support services for patients and professionals. We present three clinical scenarios to illustrate how these competencies must work together. We conclude that effective shared decision making takes time to deliver proficiently and that among other measures, policy makers must change payment models to focus on value and support education and discussion of competencies for a modern health care system.

The rotational approach to medical education: time to confront our assumptions?

Medical Education 2011: 45: 69–80

Lost in Transition: The Experience and Impact of Frequent Changes in the Inpatient Learning Environment

Purpose The traditional “rotating” model of inpatient training remains the gold standard of residency, moving residents through different systems every two to four weeks. The authors studied the experience and impact of frequent transitions on residents. Method This was a qualitative study. Ninety-seven individuals participated in 12 focus groups at three academic medical centers purposefully chosen to represent a range of geographic locations and structural characteristics. Four groups were held at each site: residents only, faculty only, nurses and ancillary staff only, and a mixed group. Grounded theory was used to analyze data. Results Perceived benefits of transitions included the ability to adapt to new environments and practice styles, improved organization and triage skills, increased comfort with stressful situations, and flexibility. Residents primarily relied on each other to cope with and prepare for transitions, with little support from the program or faculty level. Several potentially problematic workarounds were described within the context of transitions, including shortened progress notes, avoiding pages, hiding information, and sidestepping critical situations. Nearly all residents acknowledged that frequent transitions contributed to a lack of ownership and other potentially harmful effects for patient care. Conclusions These findings challenge the value of the traditional “rotating” model in residency. As residents adapt to frequent transitioning, they implicitly learn to value flexibility and efficiency over relationship building and deep system knowledge. These findings raise significant implications for professional development and patient care and highlight an important element of the hidden curriculum embedded within the current training model.

Quality improvement in small office settings: an examination of successful practices

BackgroundPhysicians in small to moderate primary care practices in the United States (U.S.) (<25 physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives.MethodsWe undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities.ResultsPhysicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers.ConclusionThese findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.

The utility of vignettes to stimulate reflection on professionalism: theory and practice

Professionalism remains a substantive theme in medical literature. There is an emerging emphasis on sociological and complex adaptive systems perspectives that refocuses attention from just the individual role to working within one’s system to enact professionalism in practice. Reflecting on responses to professional dilemmas may be one method to help practicing physicians identify both internal and external factors contributing to (un) professional behavior. We present a rationale and theoretical framework that supports and guides a reflective approach to the self assessment of professionalism. Guided by principles grounded in this theoretical framework, we developed and piloted a set of vignettes on professionally challenging situations, designed to stimulate reflection in practicing physicians. Findings show that participants found the vignettes to be authentic and typical, and reported the group experience as facilitative around discussions of professional ambiguity. Providing an opportunity for physicians to reflect on professional behavior in an open and safe forum may be a practical way to guide physicians to assess themselves on professional behavior and engage with the complexities of their work. The finding that the focus groups led to reflection at a group level suggests that effective reflection on professional behavior may require a socially interactive process. Emphasizing both the behaviors and the internal and external context in which they occur can thus be viewed as critically important for understanding professionalism in practicing physicians.

It depends: results of a qualitative study investigating how practicing internists approach professional dilemmas.

Purpose Context has a critical influence on individuals’ behaviors and is essential to understanding lapses in professionalism, yet little is known about contextual factors relevant to practicing physicians. This study used standardized professionalism dilemmas, or challenges, to explore practicing internists’ reasoning in their handling of typical challenges. Method In spring 2011, the authors created several professional challenges relevant to physicians in practice and conducted five focus groups with practicing internists (n = 40). Each group discussed five or six of the challenges, and the facilitators specifically asked what the participants would do and why. The authors used constructivist grounded theory to analyze the transcripts. Results The scenarios were effective in eliciting discussion and debate. Analysis revealed many guiding principles (e.g., patient welfare, keeping patients happy) that influenced physicians in their approach to professionalism challenges, but these principles were highly context-dependent. The authors found individuals’ responses to be malleable and subject to much modification depending on input from peers. Responses often shifted in an iterative and complex manner, depending on factors such as the “type” of patients (including the physician’s personal feelings toward them), the nature of the illness or diagnosis, and the physician’s relationships with others. Conclusions Despite recognizing and articulating basic guiding principles of professionalism, physicians’ approaches to professional challenges were subject to multiple, interdependent, idiosyncratic forces unique to each situation. A deeper understanding of these factors and how they interact is critical for the development of strategies to teach and evaluate professionalism in practice.

The role of physician engagement on the impact of the hospital-based practice improvement module (PIM)†

BACKGROUND Physicians play an important role in hospital quality improvement (QI) activities. The Hospital-Based Practice Improvement Module (Hospital PIM) is a web-based assessment tool designed by the American Board of Internal Medicine (ABIM) to facilitate physician involvement in QI as a part of maintaining certification. OBJECTIVE The primary objective of this study is to explore the impact of the Hospital PIM on physicians participating in hospital-based QI. DESIGN Qualitative design consisting of semistructured telephone interviews. PARTICIPANTS A purposeful sample of 21 early-completers of the Hospital PIM. MEASUREMENTS Grounded-theory analysis was used to analyze transcripts of the semistructured telephone interviews. RESULTS Physician completers of the Hospital PIM describe the impact in a variety of ways, including new learning about QI principles and activities, added value to their practice, and enhanced QI experience. An emerging theme was the mediating role of physician engagement in relation to the overall impact of the Hospital PIM. Four case studies illustrate these findings. Facilitators and barriers that influence the overall experience of the PIM are described. CONCLUSIONS The impact of completing the Hospital PIM is mediated by the degree of physician engagement with the QI process. Physicians who become engaged with the Hospital PIM and QI process may be more likely to report successful experiences in implementing QI activities in hospital settings than those who do not become engaged.

The Impact of a Preventive Cardiology Quality Improvement Intervention on Residents and Clinics: A Qualitative Exploration:

Teaching and evaluating quality improvement (QI) is one corollary of new competency requirements in practice- and systems-based learning and improvement. This study explored the impact of the Preventive Cardiology Practice Improvement Module (PC- PIM) on residency clinics. Results from 22 clinic interviews indicated merit in using the PC-PIM to teach QI during residency. Many residents reported increased knowledge and confidence, particularly regarding the value of QI. The majority recognized that QI often leads to improved patient care and outcomes, even in resource poor environments. Conducting aspects of the QI process themselves (eg, chart audit, decision making) led to greater awareness of the patient and systems perspectives. Barriers included a lack of resident buy-in, discontinuity of care, and a lack of institutional support. These findings shed light on how residency clinics engage in QI activities and may aid in the implementation of future QI initiatives in residency more generally. (Am J Med Qual 2009;24: 99-107)