Lisa L. Willett

A Pilot Study Using Nominal Group Technique to Assess Residents’ Perceptions of Successful Attending Rounds

ABSTRACTBACKGROUNDWard attending rounds are fundamental for internal medicine residency training. An improved understanding of interns’ and residents’ perceptions of attending rounds should inform training programs and attending physicians.OBJECTIVESThe aim of this study was to assess residents’ perceptions of successful attending rounds.DESIGNWe convened two groups of interns and two groups of residents, to elicit their perceptions on attending rounds.SUBJECTSParticipants were recruited by e-mail and conference announcements from the 49 interns and 80 residents in the internal medicine and medicine-pediatrics residency programs.MEASUREMENTSThe nominal group technique (NGT) uses a structured group process to elicit and prioritize answers to a carefully articulated question.MAIN RESULTSSeven interns (14%) identified 27 success factors and ranked attending approachability and enthusiasm and high quality teaching as most important. A second group of six (12%) interns identified 40 detractors and ranked having “mean attendings,” receiving disrespectful comments, and too long or too short rounds as the most significant detractors. Nine (11%) residents identified 32 success factors and ranked attention to length of rounds, house staff autonomy, and establishing goals/expectations as the most important success factors. A second group of six (8%) residents identified 34 detractors and ranked very long rounds, interruptions and time constraints, and poor rapport between team members as the most significant detractors).CONCLUSIONSAlthough there was some overlap in interns’ and residents’ perceptions of attending rounds, interns identified interpersonal factors as the most important factors; whereas residents viewed structural factors as most important. These findings should assist attending physicians improve the way they conduct rounds targeting both interns and residents needs.

Do women residents delay childbearing due to perceived career threats

Purpose To assess gender differences among residents regarding their plans to have children during residency and determine the most influential reasons for these differences. Method Using the Health Belief Model as a framework, the authors created an instrument to survey 424 residents from 11 residency programs at three academic medical institutions about their intentions to have children during residency. The authors developed a scale to assess the perceived career threats of having children during residency, evaluated its psychometric properties, and calculated the effect of the mediators. Results The response rate was 77% (328/424). Forty-one percent of men versus 27% of women planned to have children during residency (P = .01). The instrument measured four career threats—extended training, loss of fellowship positions, pregnancy complications, and interference with career plans—on a five-point Likert scale. The scale had a Cronbach alpha of 0.84 and an eigenvalue of 2.2. Compared with men, women had higher scores for each item and a higher mean score (2.9 versus 2.1, P = .001), signifying greater belief in the potential of pregnancy to threaten careers. After adjusting for age, institution, postgraduate year, and knowledge of parental leave policies, women were less likely to plan to have children during residency (odds ratio 0.46 [95% confidence interval 0.25–0.84]). In mediation analysis, threats to career explained 67% of the gender variance. Conclusions Women residents intentionally postpone pregnancy because of perceived threats to their careers. Medical educators should be aware of these findings when counseling female trainees.

Anticipated Consequences of the 2011 Duty Hours Standards: Views of Internal Medicine and Surgery Program Directors

Purpose To assess internal medicine (IM) and surgery program directors’ views of the likely effects of the 2011 Accreditation Council for Graduate Medical Education duty hours regulations. Method In fall 2010, investigators surveyed IM and surgery program directors, assessing their views of the likely impact of the 2011 duty hours standards on learning environment, workload, education opportunities, program administration, and patient outcomes. Results Of 381 IM program directors, 287 (75.3%) responded; of 225 surgery program directors, 118 (52.4%) responded. Significantly more surgeons than internists indicated that the new regulations would likely negatively impact learning climate, including faculty morale and residents’ relationships (P < .001). Most leaders in both specialties (80.8% IM, 80.2% surgery) felt that the regulations would likely increase faculty workload (P = .73). Both IM (82.2%) and surgery (96.6%) leaders most often rated, of all education opportunities, first-year resident clinical experience to be adversely affected (P < .001). Respondents from both specialties indicated that they will hire more nonphysician/midlevel providers (59.5% IM, 89.0% surgery, P < .001) and use more nonteaching services (66.8% IM, 70.1% surgery, P = .81). Respondents expect patient safety (45.1% IM, 76.9% surgery, P < .001) and continuity of care (83.6% IM across all training levels, 97.5% surgery regarding first-year residents) to decrease. Conclusions IM and surgery program directors agree that the 2011 duty hours regulations will likely negatively affect the quality of the learning environment, workload, education opportunities, program administration, and patient outcomes. Careful evaluation of actual impact is important.

Succeeding as a Clinician Educator: Useful Tips and Resources

Clinician Educators (CEs) play an essential role in the education and patient care missions of academic medical centers. Despite their crucial role, academic advancement is slower for CEs than for other faculty. Increased clinical productivity demands and financial stressors at academic medical centers add to the existing challenges faced by CEs. This perspective seeks to provide a framework for junior CEs to consider with the goal of maximizing their chance of academic success. We discuss six action areas that we consider central to flourishing at academic medical centers: 1. Clarify what success means and define goals; 2. Seek mentorship and be a responsible mentee; 3. Develop a niche and engage in relevant professional development; 4. Network; 5. Transform educational activities into scholarship; and 6. Seek funding and other resources.

Measuring resident physicians' performance of preventive care. Comparing chart review with patient survey

AbstractBACKGROUND: The Accreditation Council for Graduate Medical Education has suggested various methods for evaluation of practice-based learning and improvement competency, but data on implementation of these methods are limited. OBJECTIVE: To compare medical record review and patient surveys on evaluating physician performance in preventive services in an outpatient resident clinic. DESIGN: Within an ongoing quality improvement project, we collected baseline performance data on preventive services provided for patients at the University of Alabama at Birmingham (UAB) Internal Medicine Residents’ ambulatory clinic. PARTICIPANTS: Seventy internal medicine and medicine-pediatrics residents from the UAB Internal Medicine Residency program. MEASUREMENTS: Resident- and clinic-level comparisons of aggregated patient survey and chart documentation rates of (1) screening for smoking status, (2) advising smokers to quit, (3) cholesterol screening, (4) mammography screening, and (5) pneumonia vaccination. RESULTS: Six hundred and fifty-nine patient surveys and 761 charts were abstracted. At the clinic level, rates for screening of smoking status, recommending mammogram, and for cholesterol screening were similar (difference <5%) between the 2 methods. Higher rates for pneumonia vaccination (76% vs 67%) and advice to quit smoking (66% vs 52%) were seen on medical record review versus patient surveys. However, within-resident (N=70) comparison of 2 methods of estimating screening rates contained significant variability. The cost of medical record review was substantially higher (

Implementing Achievable Benchmarks in Preventive Health: A Controlled Trial in Residency Education

107 vs

Using cognitive mapping to define key domains for successful attending rounds.

17/physician). CONCLUSIONS: Medical record review and patient surveys provided similar rates for selected preventive health measures at the clinic level, with the exception of pneumonia vaccination and advising to quit smoking. A large variation among individual resident providers was noted.

Identifying Key Components for an Effective Case Report Poster: An Observational Study

Purpose To evaluate the Preventive Health Achievable Benchmarks Curriculum, a multifaceted improvement intervention that included an objective, practice-based performance evaluation of internal medicine and pediatric residents’ delivery of preventive services. Method The authors conducted a nonrandomized experiment of intervention versus control group residents with baseline and follow-up of performance audited for 2001-2004. All 130 internal medicine and 78 pediatric residents at two continuity clinics at the University of Alabama School of Medicine, Birmingham, participated. Performance of preventive care was assessed by structured chart review. The multifaceted feedback curriculum included individualized performance feedback, academic detailing by faculty, and collective didactic sessions. The main outcome was difference in receipt of preventive care for patients seen by intervention and control residents, comparing baseline and follow-up. Results Charts were reviewed for 3,958 patients. Receipt of preventive care increased for patients of intervention residents, but not for patients of control residents. For the intervention group, significant increases occurred for five of six indicators in internal medicine: smoking screening, quit smoking advice, colon cancer screening, pneumonia vaccine, and lipid screening; and four of six in pediatrics: parental quit smoking advice, car seats, car restraints, and eye alignment (p < .05 for all). For control residents, no consistent improvements were seen. There was greater improvement for intervention than for control residents for four of six indicators in internal medicine, and two of six in pediatrics. Conclusions Using a multifaceted feedback curriculum, the authors taught residents about the care they provide and improved documented patient care.

Does Residency Training Improve Performance of Physical Examination Skills

BACKGROUNDWard attending rounds are an integral part of internal medicine education. Being a good teacher is necessary, but not sufficient for successful rounds. Understanding perceptions of successful attending rounds (AR) may help define key areas of focus for enhancing learning, teaching and patient care.OBJECTIVEWe sought to expand the conceptual framework of 30 previously identified attributes contributing to successful AR by: 1) identifying the most important attributes, 2) grouping similar attributes, and 3) creating a cognitive map to define dimensions and domains contributing to successful rounds.DESIGNMulti-institutional, cross-sectional study design.PARTICIPANTSWe recruited residents and medical students from a university-based internal medicine residency program and a community-based family medicine residency program. Faculty attending a regional general medicine conference, affiliated with multiple institutions, also participated.MAIN MEASURESParticipants performed an unforced card-sorting exercise, grouping attributes based on perceived similarity, then rated the importance of attributes on a 5-point Likert scale. We translated our data into a cognitive map through multi-dimensional scaling and hierarchical cluster analysis.KEY RESULTSThirty-six faculty, 49 residents and 40 students participated. The highest rated attributes (mean rating) were “Teach by example (bedside manner)” (4.50), “Sharing of attending’s thought processes” (4.46), “Be approachable—not intimidating” (4.45), “Insist on respect for all team members” (4.43), “Conduct rounds in an organized, efficient & timely fashion” (4.39), and “State expectations for residents/students” (4.37). Attributes were plotted on a two-dimensional cognitive map, and adequate convergence was achieved. We identified five distinct domains of related attributes: 1) Learning Atmosphere, 2) Clinical Teaching, 3) Teaching Style, 4) Communicating Expectations, and 5) Team Management.CONCLUSIONSWe identified five domains of related attributes essential to the success of ward attending rounds.

Differences in preventive health quality by residency year. Is seniority better

BACKGROUNDResidents demonstrate scholarly activity by presenting posters at academic meetings. Although recommendations from national organizations are available, evidence identifying which components are most important is not.OBJECTIVETo develop and test an evaluation tool to measure the quality of case report posters and identify the specific components most in need of improvement.DESIGNFaculty evaluators reviewed case report posters and provided on-site feedback to presenters at poster sessions of four annual academic general internal medicine meetings. A newly developed ten-item evaluation form measured poster quality for specific components of content, discussion, and format (5-point Likert scale, 1 = lowest, 5 = highest).Main outcome measure(s): Evaluation tool performance, including Cronbach alpha and inter-rater reliability, overall poster scores, differences across meetings and evaluators and specific components of the posters most in need of improvement.RESULTSForty-five evaluators from 20 medical institutions reviewed 347 posters. Cronbach’s alpha of the evaluation form was 0.84 and inter-rater reliability, Spearman’s rho 0.49 (p < 0.001). The median score was 4.1 (Q1 -Q3, 3.7-4.6)(Q1 = 25th, Q3 = 75th percentile). The national meeting median score was higher than the regional meetings (4.4 vs, 4.0, P < 0.001). We found no difference in faculty scores. The following areas were identified as most needing improvement: clearly state learning objectives, tie conclusions to learning objectives, and use appropriate amount of words.CONCLUSIONSOur evaluation tool provides empirical data to guide trainees as they prepare posters for presentation which may improve poster quality and enhance their scholarly productivity.