Raquel Buranosky

Understanding Turning Points in Intimate Partner Violence: Factors and Circumstances Leading Women Victims Toward Change

OBJECTIVE When counseling women experiencing intimate partner violence (IPV), healthcare providers can benefit from understanding the factors contributing to a womens motivation to change her situation. We wished to examine the various factors and situations associated with turning points and change seeking in the IPV situation. METHODS We performed qualitative analysis on data from 7 focus groups and 20 individual interviews with women (61 participants) with past and/or current histories of IPV. RESULTS The turning points women identified fell into 5 major themes: (1) protecting others from the abuse/abuser; (2) increased severity/humiliation with abuse; (3) increased awareness of options/access to support and resources; (4) fatigue/recognition that the abuser was not going to change; and (5) partner betrayal/infidelity. CONCLUSIONS Women experiencing IPV can identify specific factors and events constituting turning points or catalyst to change in their IPV situation. These turning points are dramatic shifts in beliefs and perceptions of themselves, their partners, and/or their situation that alter the womens willingness to tolerate the situation and motivate them to consider change. When counseling women experiencing IPV, health providers can incorporate understanding of turning points to motivate women to move forward in their process of changing their IPV situation.

Competency-Based Education and Training in Internal Medicine

Recent efforts to improve medical education include adopting a new framework based on 6 broad competencies defined by the Accreditation Council for Graduate Medical Education. In this article, the Alliance for Academic Internal Medicine Education Redesign Task Force II examines the advantages and challenges of a competency-based educational framework for medical residents. Efforts to refine specific competencies by developing detailed milestones are described, and examples of training program initiatives using a competency-based approach are presented. Meeting the challenges of a competency-based framework and supporting these educational innovations require a robust faculty development program. Challenges to competency-based education include teaching and evaluating the competencies related to practice-based learning and improvement and systems-based practice, as well as implementing a flexible time frame to achieve competencies. However, the Alliance for Academic Internal Medicine Education Redesign Task Force II does not favor reducing internal medicine training to less than 36 months as part of competency-based education. Rather, the 36-month time frame should allow for remediation to address deficiencies in achieving competencies and for diverse enrichment experiences in such areas as quality of care and practice improvement for residents who have demonstrated skills in all required competencies.

Patient Satisfaction in Resident and Attending Ambulatory Care Clinics

OBJECTIVE: To measure and compare patient satisfaction with care in resident and attending physician internal medicine ambulatory care clinics.DESIGN: A cross-sectional survey using a questionnaire derived from the Visit-Specific Satisfaction Questionnaire (VSQ) and Patient Satisfaction Index (PSI) distributed from March 1998 to May 1998.SETTING: Four clinics based at a university teaching hospital and the associated Veterans’ Affairs (VA) hospital.PARTICIPANTS: Two hundred eighty-eight patients of 76 resident and 25 attending physicians.RESULTS: Patients of resident physicians at the university site were more likely to be African American, male, have lower socioeconomic status and have lower physical and mental health scores on the Short Form-12 than patients of university attendings. Patients of resident and attending physicians at the VA site were similar. In multivariate analyses, patients of university attending physicians were more likely to be highly satisfied than patients of university residents on the VSQ-Physician (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.6 to 7.8) and the PSI-Physician (OR, 10.1; 95% CI, 3.7 to 27.4) summary scores. Differences were not seen on the summary scores at the VA site. Two individual items displayed significant differences between residents and attendings at both sites: “personal manner (courtesy, respect, sensitivity, friendliness) of the doctor” (P≤.03 at both sites) and “my doctor always treats me with the highest respect” (P<.001 at both sites).CONCLUSIONS: After controlling for patient characteristics, patients of resident physicians were less satisfied than those of attending physicians, especially in regard to the doctor’s personal manner and respect toward the patient. Medical education should continue to emphasize the importance of these aspects of the physician-patient encounter.

Transforming Primary Care Training—Patient-Centered Medical Home Entrustable Professional Activities for Internal Medicine Residents

ABSTRACTINTRODUCTIONThe U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice.AIMWe address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs?PROGRAM DESCRIPTIONThe 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, ‘medical home builder’ tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs).RESULTSThe competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs.DISCUSSIONThe list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Routine Screening for Intimate Partner Violence in an Obstetrics and Gynecology Clinic

Intimate partner violence affects 5% to 22% of women seen in primary care settings.1–4 Routine screening of all adult women is recommended by advocacy and medical organizations.5–7 However, implementation of screening has not been studied outside of a research intervention. Physician barriers to screening include concerns about time, training, and lack of available treatments.8,9 Women report barriers to disclosure, such as confidentiality concerns, shame, and fear of escalating violence or loss of child custody.10,11

Effect of an educational Inpatient Diabetes Management Program on medical resident knowledge and measures of glycemic control: a randomized controlled trial.

OBJECTIVE To investigate the effectiveness of an Inpatient Diabetes Management Program (IDMP) on physician knowledge and inpatient glycemic control. METHODS Residents assigned to General Internal Medicine inpatient services were randomized to receive the IDMP (IDMP group) or usual education only (non-IDMP group). Both groups received an overview of inpatient diabetes management in conjunction with reminders of existing order sets on the hospital Web site. The IDMP group received print copies of the program and access to an electronic version for a personal digital assistant (PDA). A Diabetes Knowledge Test (DKT) was administered at baseline and at the end of the 1-month rotation. The frequency of hyperglycemia among patients under surveillance by each group was compared by using capillary blood glucose values and a dispersion index of glycemic variability. IDMP users completed a questionnaire related to the program. RESULTS Twenty-two residents participated (11 in the IDMP group and 11 in the non-IDMP group). Overall Diabetes Knowledge Test scores improved in both groups (IDMP: 69% ± 1.7% versus 83% ± 2.1%, P = .003; non-IDMP: 76% ± 1.2% versus 84% ± 1.4%, P = .02). The percentage of correct responses for management of corticosteroid-associated hyperglycemia (P = .004) and preoperative glycemic management (P = .006) improved in only the IDMP group. The frequency of hyperglycemia (blood glucose level >180 mg/dL) and the dispersion index (5.3 ± 7.6 versus 3.7 ± 5.6; P = .2) were similar between the 2 groups. CONCLUSION An IDMP was effective at improving physician knowledge for managing hyperglycemia in hospitalized patients treated with corticosteroids or in preparation for surgical procedures. Educational programs directed at improving overall health care provider knowledge for inpatient glycemic management may be beneficial; however, improvements in knowledge do not necessarily result in improved glycemic outcomes.

Faculty member review and feedback using a sign-out checklist: improving intern written sign-out.

Purpose Although residents commonly perform patient care sign-out during training, faculty do not frequently supervise or evaluate sign-out. The authors designed a sign-out checklist, and they investigated whether use of the checklist, paired with faculty member review and feedback, would improve interns’ written sign-out. Method In a randomized, controlled design in 2011, the authors compared the sign-out content and the overall sign-out summary scores of interns who received twice-monthly faculty member sign-out evaluation with those of interns who received the standard sign-out instruction. A sign-out checklist, which the authors developed on the basis of internal needs assessment and published sign-out recommendations, guided the evaluation of written sign-out content and sign-out organization as well as the twice-monthly, face-to-face evaluation that the interns in the intervention group received. Results Using the sign-out checklist and receiving feedback from a faculty member led to statistically significant improvements in interns’ sign-out. Through regression analysis, the authors calculated a 23% difference in the sign-out content (P = .005) and a 2.2-point difference in the overall summary score (on a 9-point scale, P = .009) between the interns who received sign-out feedback and those who did not. The content and quality of the intervention group’s sign-outs improved, whereas the content and quality of the control group’s worsened. Conclusions A sign-out checklist paired with twice-monthly, face-to-face feedback from a faculty member led to improvements in the content and quality of interns’ written sign-out.

Once Is Not Enough: Effective Strategies for Medical Student Education on Intimate Partner Violence

Training in intimate partner violence (IPV) improves health professionals’ knowledge and comfort regarding IPV; the optimal training frequency and format is unknown. We assessed how various types and amounts of IPV education for medical students affected knowledge and attitudes. Medical students at a large, urban university completed a survey concerning IPV-related knowledge and attitudes and participation in didactic and experiential IPV training activities. This was a one-time assessment. Of 586 students, 279 (48%) completed the survey. IPV-related knowledge increased with increased number of training activities. Knowledge and attitude scores were higher (p < .001) for respondents with experiential, versus only didactic, activities.

AAIM Report on Master Teachers and Clinician Educators Part 2: faculty development and training.

AIM Report on Master Teachers and Clinician ducators Part 2: Faculty Development and Training tephen A. Geraci, MD, Regina A. Kovach, MD, Stewart F. Babbott, MD, Harry Hollander, MD, aquel Buranosky, MD, Donna R. Devine, BS, Lee Berkowitz, MD Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Mississippi School of edicine, Jackson; Division of General Internal Medicine, Department of Medicine, Southern Illinois University School of edicine, Springfield; Division of General and Geriatric Medicine, Department of Medicine, University of Kansas School of edicine, Kansas City; Division of Infectious Diseases, Department of Medicine, University of California, San Francisco; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pa; Department of Medicine, niversity of Washington, Seattle; Department of Medicine, University of North Carolina at Chapel Hill.

Helping women victims of intimate partner violence: comparing the approaches of two health care settings

Health professionals from two different clinical settings were asked about their comfort level in dealing with intimate partner violence (IPV). Focus groups and semistructured interviews were used to gather information. Staff in an obstetrics and gynecology setting relatively rich in IPV resources described feeling capable dealing with IPV. The staff in a general medicine setting dedicated to women’s health but without a focus on IPV and with fewer supports described discomfort and difficulty dealing with IPV. Presence of systemic prioritization of and resources for IPV were described as contributing to the confidence in addressing the issue. Other necessary elements identified included (a) on-site resources, (b) adequate time, (c) focused IPV training, and (d) a team or systemic approach.