Frederick M. Chen

A Call for Outcomes Research in Medical Education

The primary goal of medical education is to produce physicians who deliver high-quality health care. Recent calls for greater accountability in medical education and the development of outcomes research methodologies should encourage a new research effort to examine the effects of medical training upon clinical outcomes. The authors offer a research agenda that links medical education and quality of health care and give specific examples of potential research projects that would begin to examine that relationship. A proposed model of patient outcomes research in medical education recognizes the contributory effects of health care system-level factors as well as the continuum of medical education, process measures, and individual training and preparedness to deliver high-quality care. There exists an opportunity to create a research agenda in medical education outcomes research that is multidisciplinary, broad based, and focused on patient-centered outcomes.

Patients’ Beliefs About Racism, Preferences for Physician Race, and Satisfaction With Care

PURPOSE Few studies have attempted to link patients’ beliefs about racism in the health care system with how they use and experience health care. METHODS Using telephone survey data from a national sample of 1,479 whites, 1,189 African Americans, and 983 Latinos, we explored patients’ beliefs about racism, their preferences for the race and ethnicity of their physician, and their satisfaction with that physician. A scale was developed to reflect patients’ beliefs about racism. Race-stratified analyses assessed associations between patients’ beliefs, racial preferences for physicians, choice of physician, and satisfaction with care. RESULTS Among African Americans, stronger beliefs about racial discrimination in health care were associated with preferring an African American physician (P <.001). Whereas only 22% of African Americans preferred an African American physician, those who preferred a African American physician and had an African American physician were more likely to rate their physician as excellent than did African Americans who preferred a African American physician but had a non–African American physician (57% vs 20%, P <.001). Latinos with stronger beliefs about discrimination in health care were more likely to prefer a Latino physician (P <.001). One third of Latinos preferred a Latino physician. Though not statistically significant, those who preferred and had a Latino physician rated their physician higher than Latinos who preferred a Latino physician but had a non-Latino physician (40% vs 29%). CONCLUSIONS Many African Americans and Latinos perceive racism in the health care system, and those who do are more likely to prefer a physician of their own race or ethnicity. African Americans who have preferences are more often satisfied with their care when their own physicians match their preferences.

Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians.

Venous thromboembolism is a common condition affecting 7.1 persons per 10,000 person-years among community residents. Incidence rates for venous thromboembolism are higher in men, African-Americans, and increase substantially with age. It is critical to treat deep venous thrombosis at an early stage to avoid development of further complications, such as pulmonary embolism or recurrent deep venous thrombosis. The target audience for this guideline is all clinicians caring for patients who have been given a diagnosis of deep venous thrombosis or pulmonary embolism. The target patient population is patients receiving a diagnosis of pulmonary embolism or lower-extremity deep venous thrombosis.

Which Medical Schools Produce Rural Physicians? A 15-Year Update

Purpose Despite continued federal and state efforts to increase the number of physicians in rural areas, disparities between the supply of rural and urban physicians persist. The authors examined the training of the rural physician workforce in the United States. Method Using a national cross-sectional analysis of the 2005 American Medical Association and American Osteopathic Association Masterfile physician data, the authors examined a 10-year cohort of clinically active MD and DO physicians who graduated from medical school between 1988 and 1997. Results Eleven percent (20,037) of the physician cohort were currently practicing in a rural location in 2005. Eighteen percent (2,045) of osteopathic medical school graduates were currently practicing in a rural location. Twenty-three percent (6,282) of family physician graduates practiced in rural areas. Women continue to be less likely than men to practice in rural areas, although the gap is narrowing. Rural residency trainees were over three times more likely to practice in rural areas (RR = 3.4, P < .001). Conclusions The proportion and number of physicians entering rural practice has remained stable compared with earlier analyses. However, recent trends such as declining primary care interest are not yet reflected in these data and may portend worsening shortages of rural physicians.

Teaching Health Centers: A New Paradigm in Graduate Medical Education

The Patient Protection and Affordable Care Act of 2010 created the Teaching Health Center Graduate Medical Education (THCGME) program to provide graduate medical education (GME) funding directly to community-based health centers that expand or establish new primary care residency programs. The THCGME program was the legislations only new investment in GME, and it represents a significant departure from the Medicare GME funding system. It provides payments to ambulatory care centers for both direct and indirect GME expenses, and mandates a level of reporting from recipients that is not required for Medicare GME support. This initial look at the 11 inaugural teaching health centers (THCs) shows that they are training primary care residents in relevant delivery models (e.g., interprofessional teams, patient-centered medical homes), developing educational initiatives that address primary care practice in underserved areas, and transforming organizational and funding structures to support community-based training. The THCs plan to evaluate and report resident performance, patient quality of care, and graduate outcomes. The work of the first THCs has implications for primary care training, the GME system, and future policies and legislation aimed at strengthening the health care workforce.

Socrates was not a pimp: changing the paradigm of questioning in medical education.

The slang term “pimping” is widely recognized by learners and educators in the clinical learning environment as the act of more senior members of the medical team publicly asking questions of more junior members. Although questioning as a pedagogical practice has many benefits, pimping, as described in the literature, evokes negative emotions in learners and leads to an environment that is not conducive to adult learning. Medical educators may employ pimping as a pedagogic technique because of beliefs that it is a Socratic teaching method. Although problems with pimping have previously been identified, no alternative techniques for questioning in the clinical environment were suggested. The authors posit that using the term “pimping” to describe questioning in medical education is harmful and unprofessional, and they propose clearly defining pimping as “questioning with the intent to shame or humiliate the learner to maintain the power hierarchy in medical education.” Explicitly separating pimping from the larger practice of questioning allows the authors to make three recommendations for improving questioning practices. First, educators should examine the purpose of each question they pose to learners. Second, they should apply historic and modern interpretations of Socratic teaching methods that promote critical thinking skills. Finally, they should consider adult learning theories to make concrete changes to their questioning practices. These changes can result in questioning that is more learner centered, aids in the acquisition of knowledge and skills, performs helpful formative and summative assessments of the learner, and improves community in the clinical learning environment.

The importance of clinical outcomes in medical education research

In the 1980s, doctors treated patients with antiarrhythmic medications to suppress premature ventricular depolarisations, thereby preventing life-threatening arrhythmias – until the Cardiac Arrhythmia Suppression Trial (CAST) found that the use of those medications prevented the arrhythmias, but killed the patients in the process! CAST taught us the important difference between clinical outcomes that matter (death) and intermediate outcomes that do not (ventricular depolarisations). Twenty years later, an emphasis on outcomes research is bringing this perspective to medical education. As a recent JAMA article posed, If medicine has a high threshold for evidence of clinical care, why is there no corresponding threshold for educational effectiveness? 2

Training Residents in Community Health Centers: Facilitators and Barriers

PURPOSE Training family medicine residents in underserved settings, such as community health centers (CHCs), may provide a solution to the primary care workforce shortage. We sought to describe the facilitators and barriers to creating partnerships between CHCs and family medicine residencies (FMRs). METHODS We conducted 19 key informant interviews and 3 focus groups to identify the key factors in the CHC-FMR relationship. Audiotapes and transcripts were analyzed to identify major themes. Key informant results were validated and expanded in the focus group discussions. RESULTS Four major themes describe the CHC-FMR training partnership: mission, money, quality, and administrative/governance complexity. The CHC-FMR training affiliation is a complex relationship drawn together by a shared mission of service to the underserved, enhanced financial stability, workforce improvement, and greater educational and clinical quality. The relationship is hindered by competing primary missions, chronic underfunding, complex governing institutional regulations, and administrative challenges. In addition, the focus groups offered several policy solutions to address the barriers to CHC-FMR affiliation. CONCLUSIONS A successful CHC-FMR training partnership relies upon the development of a shared mission of education and service, as well as innovation and flexibility by the organizations that govern them.

The current state of academic centers for interprofessional education

Abstract Team-based interprofessional practice plays a central role in new models of care delivery. However, training health professionals for interprofessional practice remains a challenge. Centers for Interprofessional Education (IPE) exist at many academic institutions but have had limited success. The authors conducted telephone interviews with 12 leaders of academic centers for IPE, identified through a key informant method. Qualitative analysis of interview notes for common themes of barriers, successes, and insights. Most IPE centers in the US are small, underfunded, with no substantial staff and faculty support. Grant funding gives legitimacy, but sustainability is a major concern. Most have had success with limited educational efforts at coordinating classes, single-day events, and learning activities. While IPE centers have support from institutional leadership, they continue to face major challenges in transforming the scope and content of health professional training in their institutions.

Insights from Exemplar Practices on Achieving Organizational Structures in Primary Care

Purpose: Interprofessional practice (IPP) is associated with better patient care outcomes and patient and provider satisfaction, yet little is known about the organizational structures that support effective IPP. Methods: We selected 9 diverse clinical practice sites with exemplary IPP and conducted site visits with nonparticipant observations and interviewed 80 physicians, nurses, pharmacists, dieticians, medical and hospital assistants, nurse practitioners, physician assistants, clinic managers, physical and occupational therapists, respiratory therapists, social workers, psychologists, and others. We independently coded field notes and interviews and identified themes and trends using a grounded theory approach. Sites were evaluated for IPP using key features identified by the 2011 Interprofessional Education Collaboration Expert Panel. Results: The primary themes at sites with high IPP were coordination of care and mutual respect. Four key organizational features were associated with these 2 themes: independent responsibilities for each professional; organizational structures for providers to learn about each others roles; a structure and culture promoting accessible, frequent communication about patients; and strong leadership in IPP-supportive values. Conclusions: To achieve interprofessional collaboration, practice teams require structural supports that facilitate coordination of care and mutual respect.