Mariah Rudd

Better Medicine by Default

Background. American health care is transitioning to electronic physician ordering. These computerized systems are unique because they allow custom order interfaces. Although these systems provide great benefits, there are also potential pitfalls, as the behavioral sciences have shown that the very format of electronic interfaces can influence decision making. The current research specifically examines how defaults in electronic order templates affect physicians’ treatment decisions and medical errors. Methods. Forty-five medical residents completed order sets for 3 medical case studies. Participants were randomly assigned to receive order sets with either “opt-in” defaults (options visible but unselected) or “opt-out” defaults (options visible and preselected). Results compare error rates between conditions and examine the type and severity of errors most often made with opt-in versus opt-out defaults. Results. Opt-out defaults resulted in a greater number of items ordered and specifically increased commission errors (overordering) compared with opt-in defaults. However, while opt-in defaults resulted in fewer orders, they also increased omission errors. When the severity of the errors is taken into account, the default effects seem limited to less severe errors. Conclusion. The defaults used in electronic order sets influence medical treatment decisions when the consequences to a patient’s health are low. This pattern suggests that physicians cognitively override incorrect default choices but only to a point, and it implies tradeoffs that maximize accuracy and minimize cognitive effort. Results indicate that defaults for low-impact items on electronic templates warrant careful attention because physicians are unlikely to override them.

The professionalism disconnect: do entering residents identify yet participate in unprofessional behaviors?

BackgroundProfessionalism has been an important tenet of medical education, yet defining it is a challenge. Perceptions of professional behavior may vary by individual, medical specialty, demographic group and institution. Understanding these differences should help institutions better clarify professionalism expectations and provide standards with which to evaluate resident behavior.MethodsDuke University Hospital and Vidant Medical Center/East Carolina University surveyed entering PGY1 residents. Residents were queried on two issues: their perception of the professionalism of 46 specific behaviors related to training and patient care; and their own participation in those specified behaviors. The study reports data analyses for gender and institution based upon survey results in 2009 and 2010. The study received approval by the Institutional Review Boards of both institutions.Results76% (375) of 495 PGY1 residents surveyed in 2009 and 2010 responded. A majority of responders rated all 46 specified behaviors as unprofessional, and a majority had either observed or participated in each behavior. For all 46 behaviors, a greater percentage of women rated the behaviors as unprofessional. Men were more likely than women to have participated in behaviors. There were several significant differences in both the perceptions of specified behaviors and in self-reported observation of and/or involvement in those behaviors between institutions.Respondents indicated the most important professionalism issues relevant to medical practice include: respect for colleagues/patients, relationships with pharmaceutical companies, balancing home/work life, and admitting mistakes. They reported that professionalism can best be assessed by peers, patients, observation of non-medical work and timeliness/detail of paperwork.ConclusionDefining professionalism in measurable terms is a challenge yet critical in order for it to be taught and assessed. Recognition of the differences by gender and institution should allow for tailored teaching and assessment of professionalism so that it is most meaningful. A shared understanding of what constitutes professional behavior is an important first step.

Developing Teaching Strategies in the EHR Era: A Survey of GME Experts

BACKGROUND There is limited information on the impact of widespread adoption of the electronic health record (EHR) on graduate medical education (GME). OBJECTIVE To identify areas of consensus by education experts, where the use of EHR impacts GME, with the goal of developing strategies and tools to enhance GME teaching and learning in the EHR environment. METHODS Information was solicited from experienced US physician educators who use EPIC EHR following 3 steps: 2 rounds of online surveys using the Delphi technique, followed by telephone interviews. The survey contained 3 stem questions and 52 items with Likert-scale responses. Consensus was defined by predetermined cutoffs. A second survey reassessed items for which consensus was not initially achieved. Common themes to improve GME in settings with an EHR were compiled from the telephone interviews. RESULTS The panel included 19 physicians in 15 states in Round 1, 12 in Round 2, and 10 for the interviews. Ten items were found important for teaching and learning: balancing focus on EHR documentation with patient engagement achieved 100% consensus. Other items achieving consensus included adequate learning time, balancing EHR data with verbal history and physical examination, communicating clinical thought processes, hands-on EHR practice, minimizing data repetition, and development of shortcuts and templates. Teaching strategies incorporating both online software and face-to-face solutions were identified during the interviews. CONCLUSIONS New strategies are needed for effective teaching and learning of residents and fellows, capitalizing on the potential of the EHR, while minimizing any unintended negative impact on medical education.

Effect of Peer-to-Peer Nurse–Physician Collaboration on Attitudes Toward the Nurse–Physician Relationship

The goal of this study was to pilot a novel peer-to-peer nurse–physician collaboration program and assess for changes in attitudes toward collaboration among a group of newly licensed nurses and resident physicians (n = 39). The program included large group meetings, with discussion of key concepts related to interprofessional collaboration. In unit-based teams, the registered nurses and physicians developed a quality improvement project to meet a need on their unit. Creating learning activities like this program enable nursing professional development specialists to promote interprofessional collaboration and learning.

Sometimes determination and compromise thwart success: lessons learned from an effort to study copying and pasting in the electronic medical record

Copying/pasting, note-forwarding, and templating are common practices in the electronic medical record (EMR) even though early observations indicated a widespread belief that such behaviours would be rare [1]. Recent surveys indicate much broader acceptance and existence of copying/pasting, and other purportedly efficiency-producing behaviours than initially was predicted [2]. Medical educators and clinicians have raised concerns about the impact on notes, which may be rendered bloated or meaningless [3, 4], as well as the impact on the patient-physician relationship, the physicianlearner relationship, and the ability of learners to interact with patients [3, 5, 6]. Learners (and providers) engaging in copying/pasting and other EMR-based efficiency measures may have less in-depth knowledge about their patients [7]. Whether there is any causation in this correlation is not well studied, but studies in other fields suggest that technological multitasking may overwhelm individuals’ ability to attend to detail [8]. Educational impact of the EMR, particularly that of interpersonal and communication skills, has been discussed by previous authors [9, 10]. Of concern to us is the possibility that critically important aspects of learning (including direct patient care, professionalism and accountability) and patient care are suffering as metrics and efficiency measures are increasingly prioritized [11].

Is it a match? a novel method of evaluating medical school success

ABSTRACT Background: Medical education program evaluation allows for curricular improvements to both Undergraduate (UME) and Graduate Medical Education (GME). UME programs are left with little more than match rates and self-report to evaluate success of graduates in The Match. Objective: This manuscript shares a novel method of program evaluation through a systematic assessment of Match outcomes. Design: Surveys were developed and distributed to Program Training Directors (PTDs) at our institution to classify residency programs into which our UME graduates matched using an ordinal response scale and open-ended responses. Outcomes-based measures for UME graduates were collected and analyzed. The relationship between PTD survey data and UME graduates’ outcomes were explored. Open-ended response data were qualitatively analyzed using iterative cycles of coding and identifying themes. Results: The PTD survey response rate was 100%. 71% of our graduates matched to programs ranked as ‘elite’ (36%) or ‘top’ (35%) tier. The mean total number of ‘Honors’ grades achieved by UME graduates was 2.6. Data showed that graduates entering elite and top GME programs did not consistently earn Honors in their associated clerkships. A positive correlation was identified between USMLE Step 1 score, number of honors, and residency program rankings for a majority of the programs. Qualitative analysis identified research, faculty, and clinical exposure as necessary characteristics of ‘elite’ programs:. Factors considered by PTDs in the rating of programs included reputation, faculty, research, national presence and quality of graduates. Conclusions: This study describes a novel outcomes-based method of evaluating the success of UME programs. Results provided useful feedback about the quality of our UME program and its ability to produce graduates who match in highly-regarded GME programs. The findings from this study can benefit Clerkship Directors, Student Affairs and Curriculam Deans, and residency PTDs as they help students determine their competitiveness forspecialties and specific residency programs.

Piloting a patient safety and quality improvement co-curriculum

ABSTRACT Background: Despite the push for resident and faculty involvement in patient safety (PS) and quality improvement (QI), there is limited literature describing programs that train them to conduct PS/QI projects. Objective: To determine the effectiveness of a co-learning PS/QI curriculum. Method: The authors implemented a co-learning (residents and faculty together) PS/QI curriculum within our general Internal Medicine program over 1 year. The curriculum consisted of two workshops, between-session guidance, and final presentation. The authors evaluated effectiveness by self-assessment of attitude, knowledge, and behavior change and PS/QI project completion. Results: Thirty-eight of 32 (95%) resident and 8 faculty member participants attended the workshops and 27 of 40 (67%) completed the evaluation. Participants (87–96%) responded favorably regarding workshop effectiveness. The authors found significant improvement in 78% of items pertaining to PS/QI knowledge/skills, but no difference for attitudinal items. The final project evaluation participants rated project content as relevant to learning needs (75%); training as well-organized (75%); faculty mentorship for the project as supportive (75%); and the overall project as excellent or very good (71%). Conclusion: The authors successfully demonstrated a framework for co-teaching faculty and residents to conduct PS/QI projects. Participants acquired necessary tools to practice in an ever-evolving clinical setting emphasizing a patient-centered and quality-focused environment.

Providing successful faculty development to graduate medical education program directors

Graduate Medical Education (GME) is the portion of the medical education continuum that spans the period following graduation from medical school to independent practice. In the United States, successful completion of GME is essential for board certification in one of over 140 recognized specialties. The Accreditation Council for Graduate Medical Education (ACGME) is the accreditor for over 10,000 programs. Each program is required to have a single physician program director responsible for the program’s administrative and educational oversight. Virtually all program directors remain clinically and academically productive. Over the last 17 years, the ACGME has transitioned its accreditation emphasis to promote competency based education. Furthermore, the ACGME requires programs to provide faculty development in teaching and assessment for their faculty and to evaluate the programs performance in providing it annually.1 Some program directors, selected for their interest in teaching and advocacy for residents, have never been formally trained as educators or as educational leaders.2 Previous studies have reported that program directors feel poorly prepared to meet their educational and accreditation challenges. Among their top concerns are a lack of expertise in curriculum development and evaluation, and a lack of understanding of ACGME competencies and their assessment.3 Furthermore, faculty attrition has been linked to inadequate faculty development.4 In response, many program directors turn to external sources of professional development outside of their individual programs.5 Hafler and colleagues highlight the importance of faculty development efforts in providing knowledge and skills while facilitating a supportive community in which continual improvement of teaching and assessment becomes the norm.6 We used situational learning theory and best practices from communities of practice, to develop implement, and evaluate an institutional faculty development program for over 100 GME program directors of both ACGME accredited and internally sponsored programs. The purpose of this Perspective is to present our eight-year experience.

Mystery behind the match: an undergraduate medical education-graduate medical education collaborative approach to understanding match goals and outcomes.

Background There is a paucity of information regarding institutional targets for the number of undergraduate medical education (UME) graduates being matched to graduate medical education (GME) programs at their home institutions. At our institution, the Duke University, the number of UME graduates matched to GME programs declined dramatically in 2011. To better understand why this decline may have happened, we sought to identify perceived quality metrics for UME and GME learners, evaluate trends in match outcomes and educational program characteristics, and explore whether there is an ideal retention rate for UME graduates in their home institutions’ GME programs. Methods We analyzed the number of Duke University UME graduates remaining at Duke for GME training over the past 5 years. We collected data to assess for changing characteristics of UME and GME, and performed descriptive analysis of trends over time to investigate the potential impact on match outcomes. Results A one-sample t-test analysis showed no statistically significant difference in the number of Duke UME graduates who stayed for GME training. For both UME and GME, no significant changes in the characteristics of either program were found. Discussion We created a process for monitoring data related to the characteristics or perceived quality of UME and GME programs and developed a shared understanding of what may impact match lists for both UME graduates and GME programs, leaving the Match somewhat less mysterious. While we understand the trend of graduates remaining at their home institutions for GME training, we are uncertain whether setting a goal for retention is reasonable, and so some mystery remains. We believe there is an invaluable opportunity for collaboration between UME and GME stakeholders to facilitate discussion about setting shared institutional goals.