Judith L. Bowen

Impacts of Computerized Physician Documentation in a Teaching Hospital: Perceptions of Faculty and Resident Physicians

OBJECTIVE Computerized physician documentation (CPD) has been implemented throughout the nations Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace handwritten documentation in other institutions. The use of this technology may affect educational and clinical activities, yet little has been reported in this regard. The authors conducted a qualitative study to determine the perceived impacts of CPD among faculty and housestaff in a VAMC. DESIGN A cross-sectional study was conducted using semistructured interviews with faculty (n = 10) and a group interview with residents (n = 10) at a VAMC teaching hospital. MEASUREMENTS Content analysis of field notes and taped transcripts were done by two independent reviewers using a grounded theory approach. Findings were validated using member checking and peer debriefing. RESULTS Four major themes were identified: (1) improved availability of documentation; (2) changes in work processes and communication; (3) alterations in document structure and content; and (4) mistakes, concerns, and decreased confidence in the data. With a few exceptions, subjects felt documentation was more available, with benefits for education and patient care. Other impacts of CPD were largely seen as detrimental to aspects of clinical practice and education, including documentation quality, workflow, professional communication, and patient care. CONCLUSION CPD is perceived to have substantial positive and negative impacts on clinical and educational activities and environments. Care should be taken when designing, implementing, and using such systems to avoid or minimize any harmful impacts. More research is needed to assess the extent of the impacts identified and to determine the best strategies to effectively deal with them.

Reforming internal medicine residency training : A report from the society of general internal medicine's task force for residency reform

The structure, process, and outcomes of internal medicine residency training have concerned the profession for over 20 years.1–9 Over the last decade the initiative to move to outcomes-based education redefined the competencies physicians should obtain during training.10,11 The core principle of outcomes-based education is the objective demonstration that a graduating trainee, whether from medical school or a residency, possesses the knowledge, skills, and attitudes necessary to progress to the next stage of his or her professional career.12,13 The Accreditation Council for Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) have defined core competencies for physicians shown in Table 1.10,14 While both the ACGME and IOM provide a framework for the desired outcomes, medical educators bear the burden of designing the structures and processes to achieve them.15 Table 1 Comparison of the IOM and ACGME Competencies Educators face several key challenges in redesigning residency programs. First, residency programs must prepare trainees for a variety of general internal medicine and subspecialty careers. Second, the settings and resources for residency training are highly heterogeneous. Third, an aging and increasingly diverse population, combined with rapidly expanding medical information and procedural technology, challenges all internists to acquire and maintain the knowledge, skills, attitudes, and performance necessary to provide high-quality care within their chosen discipline.16,17 Finally, growing public dissatisfaction, substantial health care disparities, increased acuity but shorter lengths of stay for hospitalized patients, new work hour requirements, increasing medical student debt, and changing student demographics and lifestyle concerns further complicate residency reform.18–25 To provide recommendations for residency reform. The Society of General Internal Medicine (SGIM) convened a task force consisting of physicians representing a broad range of views within general medicine, expertise and experience in clinical education, and who represented internal medicine organizations outside of SGIM (Appendix 1). The task force focused on reform in 5 specific areas: ambulatory education, inpatient education, residency curriculum, health disparities, and life-long learning skills. To prepare this report, 4 subcommittees performed literature reviews that guided a prospective, systematic process to develop the final recommendations. The guiding principles, task force timeline, and the specific findings of the 4 subcommittees can be viewed at http://www.sgim.org. We acknowledge this report cannot cover all important aspects of residency training. The task force enthusiastically welcomes comments from other educators and internal medicine specialty organizations. Only through active collaboration and serious dialogue can we improve residency training.

Assessing quality and costs of education in the ambulatory setting: a review of the literature.

Purpose Time-pressured interactions with little direct observation or feedback characterize teaching in ambulatory settings. The authors report findings from the literature on teaching and learning in the ambulatory setting and propose opportunities for further research that addresses these barriers. Method The authors searched 1995–1999 databases for all empirical studies that focused on research conducted in ambulatory settings. Publications were reviewed for evidence of inclusion criteria. Findings were sorted into categories previously described for defining and evaluating quality of ambulatory care educational programs. Results Most studies were conducted in departments of internal medicine (40%), focused on medical students (43%), and took place in a single program (77%), making generalizations difficult. Students and residents are learning in ambulatory environments, and the types of patients they encounter are likely to prepare them for practice. Patient care outcomes have emerged as a measure of learning. Teachers may be the single most important factor, yet they lack self-confidence as teachers. Community-based preceptors teach because of enjoyment of teaching and the opportunity to stay current. However, none of the studies addressed the impact of the Medicare documentation requirements on satisfaction with teaching. Teaching settings cost about one third more than non-teaching settings to operate. Conclusion This review identifies many gaps in our knowledge of effective clinical teaching practices, and of learning environments in which that teaching takes place. The predominance of single-institution studies limits generalizability of current findings. A prioritized research agenda should be established and funded, focusing on improving the efficiency and effectiveness of teaching and learning in ambulatory settings.

Changing habits of practice. Transforming internal medicine residency education in ambulatory settings.

PURPOSE: The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change.METHODS: The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance.RESULTS: Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education.CONCLUSION: This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident’s level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.

There is no "i" in teamwork in the patient-centered medical home: defining teamwork competencies for academic practice.

Evidence suggests that teamwork is essential for safe, reliable practice. Creating health care teams able to function effectively in patient-centered medical homes (PCMHs), practices that organize care around the patient and demonstrate achievement of defined quality care standards, remains challenging. Preparing trainees for practice in interprofessional teams is particularly challenging in academic health centers where health professions curricula are largely siloed. Here, the authors review a well-delineated set of teamwork competencies that are important for high-functioning teams and suggest how these competencies might be useful for interprofessional team training and achievement of PCMH standards. The five competencies are (1) team leadership, the ability to coordinate team members’ activities, ensure appropriate task distribution, evaluate effectiveness, and inspire high-level performance, (2) mutual performance monitoring, the ability to develop a shared understanding among team members regarding intentions, roles, and responsibilities so as to accurately monitor one another’s performance for collective success, (3) backup behavior, the ability to anticipate the needs of other team members and shift responsibilities during times of variable workload, (4) adaptability, the capability of team members to adjust their strategy for completing tasks on the basis of feedback from the work environment, and (5) team orientation, the tendency to prioritize team goals over individual goals, encourage alternative perspectives, and show respect and regard for each team member. Relating each competency to a vignette from an academic primary care clinic, the authors describe potential strategies for improving teamwork learning and applying the teamwork competences to academic PCMH practices.

Protecting time for teaching in the ambulatory care setting.

The current drive for efficient clinical teaching threatens the educational mission of academic medical centers. With pressures to increase clinical productivity, protected time and compensation for teaching have become scarce resources for clinical teachers in all settings. Although it may yield new approaches to education, the push for efficiency may ultimately result in insufficient time for teaching and may cause some clinical preceptors to stop teaching completely. Further, it may lead to the illusion that comprehensive teaching truly requires little time. Since the future of American health care depends upon the provision of high-quality clinical education to young physicians, this situation presents a potential national crisis. In this article, the authors discuss the complex nature of teaching, its time requirements, and the special challenges of teaching in outpatient settings. To avoid overemphasizing efficiency to the detriment of education they recommend adhering to two principles: (1) academic medical centers are educational as well as training institutions, and therefore should provide a broad-based education as well as training in clinical skills; and (2) the clinical teaching process is complex and adequate time must be provided for its many phases, including planning, instructing, and reflecting. Finally, the authors make recommendations for ensuring the delivery of high-quality education in ambulatory care settings.

Comparing diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought.

Purpose Although decades of research have yielded considerable insight into physicians’ clinical reasoning processes, assessing these processes remains challenging; thus, the authors sought to compare diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought. Method This 2011–2012 multicenter randomized study of 393 clinicians (medical students, postgraduate trainees, and faculty) measured diagnostic accuracy on clinical vignettes under two conditions: one encouraged participants to give their first impression (FI), and the other led participants through a directed search (DS) for the correct diagnosis. The authors compared accuracy, feasibility, reliability, and relation to United States Medical Licensing Exam (USMLE) scores under each condition. Results A 2 (instructional condition) × 2 (vignette complexity) × 3 (experience level) analysis of variance revealed no difference in accuracy as a function of instructional condition (F[1,379] = 2.44, P = .12), but demonstrated the expected main effects of vignette complexity (F[1,379] = 965.2, P < .001) and experience (F[2,379] = 39.6, P < .001). Pearson correlations revealed greater associations between assessment scores and USMLE performance in the FI condition than in the DS condition (P < .001). Spearman–Brown calculations consistently indicated that alpha ≥ 0.75 could be achieved more efficiently under the FI condition relative to the DS condition. Conclusions Instructions to trust one’s first impres-sions result in similar performance when compared with instructions to consider clinical information in a systematic fashion, but have greater utility when used for the purposes of assessment.

Learning in the Social Context of Ambulatory Care Clinics.

Social learning theory describes the process by which medical students and residents become members of the professional community of physicians. According to this theory, learning is enhanced when students and residents can share with each other their partial understandings and when they can observe and emulate the thinking and actions of expert role models. The authors make several recommendations for how social learning theory may be applied to education in ambulatory care settings: (1) preceptors should pay careful attention to orienting learners and creating legitimate roles for learners appropriate to their levels of training and ability and their educational needs; (2) since students and residents learn by observing and interacting with preceptors, competent role models should be provided; (3) to be most effective, learners should be told in advance what will be modeled, observe the demonstration, discuss what occurred and why it did or did not work effectively, and, finally, be given the opportunity to practice new actions, first with guidance and later independently; (4) when debriefing about modeled interactions, preceptors should encourage self-monitoring and self-assessment; (5) preceptors should create opportunities for collaborative learning, because collaboration with peers allows learners to discover their own misconceptions and help others to develop a richer understanding of medical practice. Implementing these guidelines in ambulatory care training will enable learners and preceptors to arrive at the shared meanings and common understandings that form the foundation of the professional medical community.

Uncovering frustrations. A qualitative needs assessment of academic general internists as geriatric care providers and teachers.

BACKGROUND: General internists commonly provide medical care for older adults and geriatric education to trainees, but lack the necessary knowledge and skills to fulfill these tasks.OBJECTIVE: Assess the geriatric training needs of academic general internists in 3 hospital systems in Portland, OR.DESIGN: Ten focus groups and 1 semi-structured interview. Interview transcripts were analyzed using thematic analysis, a well-recognized qualitative technique.PARTICIPANTS: A convenience sample of 22 academic general internists and 8 geriatricians from 3 different teaching hospitals.MEASUREMENTS: We elicited stories of frustration and success in caring for elderly patients and in teaching about their care. We asked geriatricians to recount their experiences as consultants to general internists and to comment on the training of Internists in geriatrics.RESULTS: In addition to deficits in their medical knowledge and skills, our Internists reported frustration with the process of delivering care to older adults. In particular, they felt ill prepared to guide care transitions for patients, use multidisciplinary teams effectively, and were frustrated with health care system issues. Additionally, general internists’ approach to medical care, which largely relies on the medical model, is different from that of geriatricians, which focuses more on social and functional issues.CONCLUSIONS: Although our findings may not be broadly representative, improving our general internists’ abilities to care for the elderly and to teach learners how to do the same should address deficits in medical knowledge and skills, barriers to the processes of delivering care, and philosophical approaches to care. Prioritizing and quantifying these needs and measuring the effectiveness of curricula to address them are areas for future research.

Connecting the dots: interprofessional health education and delivery system redesign at the Veterans Health Administration.

Health systems around the United States are embracing new models of primary care using interprofessional team-based approaches in pursuit of better patient outcomes, higher levels of satisfaction among patients and providers, and improved overall value. Less often discussed are the implications of new models of care for health professions education, including education for physicians, nurse practitioners, physician assistants, and other professions engaged in primary care. Described here is the interaction between care transformation and redesign of health professions education at the largest integrated delivery system in the United States: the Veterans Health Administration (VA). Challenges and lessons learned are discussed in the context of a demonstration initiative, the VA Centers of Excellence in Primary Care Education. Five sites, involving VA medical centers and their academic affiliates in Boise, Cleveland, San Francisco, Seattle, and West Haven, introduced interprofessional primary care curricula for resident physicians and nurse practitioner students beginning in 2011. Implementation struggles largely revolved around the operational logistics and cultural disruption of integrating educational redesign for medicine and nursing and facilitating the interface between educational and clinical activities. To realize new models for interprofessional teaching, faculty, staff, and trainees must understand the histories, traditions, and program requirements across professions and experiment with new approaches to achieving a common goal. Key recommendations for redesign of health professions education revolve around strengthening the union between interprofessional learning, team-based practice, and high-value care.