F. Daniel Duffy

Assessing competence in communication and interpersonal skills: the Kalamazoo II report.

Accreditation of residency programs and certification of physicians requires assessment of competence in communication and interpersonal skills. Residency and continuing medical education program directors seek ways to teach and evaluate these competencies. This report summarizes the methods and tools used by educators, evaluators, and researchers in the field of physician–patient communication as determined by the participants in the “Kalamazoo II” conference held in April 2002. Communication and interpersonal skills form an integrated competence with two distinct parts. Communication skills are the performance of specific tasks and behaviors such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills are inherently relational and process oriented; they are the effect communication has on another person such as relieving anxiety or establishing a trusting relationship. This report reviews three methods for assessment of communication and interpersonal skills: (1) checklists of observed behaviors during interactions with real or simulated patients; (2) surveys of patients’ experience in clinical interactions; and (3) examinations using oral, essay, or multiple-choice response questions. These methods are incorporated into educational programs to assess learning needs, create learning opportunities, or guide feedback for learning. The same assessment tools, when administered in a standardized way, rated by an evaluator other than the teacher, and using a predetermined passing score, become a summative evaluation. The report summarizes the experience of using these methods in a variety of educational and evaluation programs and presents an extensive bibliography of literature on the topic. Professional conversation between patients and doctors shapes diagnosis, initiates therapy, and establishes a caring relationship. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the physician. This report focuses on how the physicians competence in professional conversation with patients might be measured. Valid, reliable, and practical measures can guide professional formation, determine readiness for independent practice, and deepen understanding of the communication itself.

Promoting physicians' self‐assessment and quality improvement: The ABIM diabetes practice improvement module

Introduction: The American Board of Internal Medicine (ABIM) recognized that certification and recertification must be based on an assessment of performance in practice as well as an examination of medical knowledge. Physician self‐assessment of practice performance is proposed as one method that certification boards may use to evaluate competence in practice‐based learning and improvement and systems‐based practice. Methods: Sixteen practicing general internists and endocrinologists with 10‐year time‐limited certification participated in a beta test of the ABIMs diabetes practice improvement module (PIM) as part of their recertification program. A PIM consists of a self‐directed medical record audit, practice system survey, and patient survey. A quality improvement education specialist from the Connecticut Quality Improvement Organization provided on‐site and distance consultation on quality improvement methods and tools. An independent audit assessed the reliability of physician self‐audit. Qualitative interviews were conducted at 2 time points to assess for physician satisfaction and behavioral change in quality improvement. Results: Fourteen physicians completed the diabetes PIM. All but 1 physician found the medical record audit to provide important information about the practice. Of the 11 physicians who completed a follow‐up interview, 10 stated that the quality improvement education specialist helped improve their practice. Discussion: Self‐assessment using the ABIM diabetes PIM as part of recertification provides valuable practice information and can lead to meaningful behavioral change by physicians. Collaboration with an educator in quality improvement appears to facilitate the effects of the practice improvement module. Future work should investigate the effect on patient outcomes.

Variation in Internal Medicine Residency Clinic Practices: Assessing Practice Environments and Quality of Care

BackgroundFew studies have systematically and rigorously examined the quality of care provided in educational practice sites.ObjectiveThe objectives of this study were to (1) describe the patient population cared for by trainees in internal medicine residency clinics; (2) assess the quality of preventive cardiology care provided to these patients; (3) characterize the practice-based systems that currently exist in internal medicine residency clinics; and (4) examine the relationships between quality, practice-based systems, and features of the program: size, type of program, and presence of an electronic medical record.DesignThis is a cross-sectional observational study.SettingThis study was conducted in 15 Internal Medicine residency programs (23 sites) throughout the USA.ParticipantsThe participants included site champions at residency programs and 709 residents.MeasurementsAbstracted charts provided data about patient demographics, coronary heart disease risk factors, processes of care, and clinical outcomes. Patients completed surveys regarding satisfaction. Site teams completed a practice systems survey.ResultsChart abstraction of 4,783 patients showed substantial variability across sites. On average, patients had between 3 and 4 of the 9 potential risk factors for coronary heart disease, and approximately 21% had at least 1 important barrier of care. Patients received an average of 57% (range, 30–77%) of the appropriate interventions. Reported satisfaction with care was high. Sites with an electronic medical record showed better overall information management (81% vs 27%) and better modes of communication (79% vs 43%).ConclusionsThis study has provided insight into the current state of practice in residency sites including aspects of the practice environment and quality of preventive cardiology care delivered. Substantial heterogeneity among the training sites exists. Continuous measurement of the quality of care provided and a better understanding of the training environment in which this care is delivered are important goals for delivering high quality patient care.

A three-part model for measuring diabetes care in physician practice.

Background To assess the psychometric properties of the three components of the Diabetes Practice Improvement Module, to compare reliabilities of composites to individual measures, and to identify associations among practice-based and patient-based measures. Method Data include practice systems surveys of 626 physicians, 13,965 chart audits, and 12,927 patient surveys. Quality composites were identified using factor analysis. Means with reliabilities (intraclass correlation coefficient [ICC] and Cronbach’s α) are reported. Associations among patient-based quality measures and practice measures with case-mix adjustments were estimated via hierarchical models. Results Composite ICCs range from 0.11 to 0.54, and single items range from 0.05 to 0.49. Staff communication, efficiency, care access, and patient knowledge correlate with patient satisfaction (P < .001). Clinical outcomes are associated with clinical processes (e.g., annual foot exam) and appropriate treatment (P < .001). Patient adjusters (e.g., overall health or factors limiting self-care) are important for the models; physician characteristics used (e.g., age, practice size) seem less important. Conclusions Composites require smaller patient sample sizes and result in more reliable measures than do individual items. Additionally, the data show meaningful relationships between composites; physician-directed components (i.e., clinical processes and treatments) are related to clinical outcomes, and patients are clearly more satisfied with care if it is easily accessible and if communication about care is good.

The Teaching of Chest Auscultation During Primary Care Training: Has Anything Changed in the 1990s?

OBJECTIVE To survey the teaching time and importance given to cardiopulmonary auscultation during internal medicine (IM) and family practice (FP) residencies, and to compare current practices to those of the early 1990s. DESIGN A nationwide mail survey of IM and FP program directors (PDs). SETTING All Accreditation Council for Graduate Medical Education-accredited IM and FP residencies. PARTICIPANTS A total of 538 of 939 PDs (57.5%). MEASUREMENTS AND MAIN RESULTS In contrast to the early 1990s, when there had been no significant difference in teaching practices between IM and FP programs, more IM than FP residencies taught cardiopulmonary auscultation in 1999 (cardiac auscultation: IM residencies, 48%; FP residencies, 29.2% [p < 0.001]; pulmonary auscultation: IM residencies, 23.7%; FP residencies, 12.2% [p < 0.001]). Across the decade there also had been a significant increase in the percentage of IM programs offering structured education in chest auscultation (cardiac auscultation increase, 27.1 to 48% [p < 0.001]; pulmonary auscultation increase, 14.1 to 23.7% [p < 0.02]), but no significant changes for FP residencies. IM PDs gave more clinical importance to auscultation and expressed a greater desire for expanded teaching than did their counterparts in FP programs. CONCLUSIONS This study indicates a significant gain over the last decade in the percentage of IM residencies offering structured teaching of cardiopulmonary auscultation. This same gain did not occur for FP programs. Whether these differences in attitudes and teaching practices will translate into improved auscultatory proficiency of IM trainees will need to be determined.

Improving the Quality of Care via Maintenance of Certification and the Web: An Early Status Report

Few question the need for continuous professional development throughout a physicians career, but rapid changes in health care are creating demand for physicians to acquire new knowledge, skills, and attitudes to implement quality improvement in clinical practice. The Internet and World Wide Web are technologies that have the potential to facilitate deep change in physician practice and lifelong learning. This paper describes how the American Board of Internal Medicine (ABIM) has utilized the Web and the Internet to engage physicians in the competencies of practice-based learning and improvement and systems-based practice. Specifically, we describe how the ABIM developed and implemented Web-based practice improvement modules (PIMs) to help physicians measure and improve their clinical practice.

Changing the culture of a medical school by orienting students and faculty toward community medicine.

Oklahoma’s health status has been ranked among the worst in the country. In 1972, the University of Oklahoma established the Tulsa branch of its College of Medicine (COM) to expand the physician workforce for northeastern Oklahoma and to provide care for the uninsured patients of the area. In 2008, the Tulsa branch launched a distinct educational track, the University of Oklahoma COM’s School of Community Medicine (SCM), to prepare providers equipped and committed to addressing prevalent health disparities. The authors describe the Tulsa branch’s Summer Institute (SI), a signature program of the SCM, and how it is part of SCM’s process of institutional transformation to align its education, service, and research missions toward improving the health status of the entire region. The SI is a weeklong, prematriculation immersion experience in community medicine. It brings entering medical and physician assistant students together with students and faculty from other disciplines to develop a shared culture of community medicine. The SI uses an unconventional curriculum, based on Scharmer’s Theory U, which emphasizes appreciative inquiry, critical thinking, and collaborative problem solving. Also, the curriculum includes Professional Meaning conversations, small-group sessions to facilitate the integration of students’ observations into their professional identities and commitments. Development of prototypes of a better health care system enables participants to learn by doing and to bring community medicine to life. The authors describe these and other curricular elements of the SI, present early evaluation data, and discuss the curriculum’s incremental evolution. A longitudinal outcomes evaluation is under way.

Commentary: training internists for practice focused on meeting patient needs.

The author describes the evolution of practice within the broad specialty of internal medicine. This evolution is driven by scientific discovery, emergent patient needs, and market forces. Four ages describe the evolution: the age of the Oslerian diagnostic consultant, the age of the subspecialist, the age of the primary care internist, and the emerging age of focused general internal medicine practice. The author suggests that competence in practice-based learning and improvement linked with evaluation of practice performance throughout a career permits the professions to abandon the notion that valid learning for medical practice occurs only by completing a designated number of months of residency or fellowship training. By applying competency-based standards for specialty certification and maintaining its validity for current practice, boards can provide trainees and practitioners a tool for professional accountability for initial and continuous professional competence. The lifelong learning and evaluation process permits the timely recognition of proficiency acquired in practice. This process engages internists in ongoing guided reflection on measures of performance and provides evidence that they have incorporated new knowledge, technology, skills, and attitudes that align their practice with patient needs. As dialogue with internal medicine stakeholders and customers continues, the author describes how the training standards for certification might adapt to the evolving demands for the specialty practice and how the evaluation of continuous professional development through the maintenance of certification provides an instrument for identifying and recognizing proficiency in providing focused care within the broad discipline of internal medicine.