Scott M. Wright

A Quality Improvement Intervention to Facilitate the Transition of Older Adults from Three Hospitals Back to Their Homes

OBJECTIVES: To study the feasibility and effectiveness of a discharge planning intervention.

Attributes of Excellent Attending-Physician Role Models

Background Although effective role models are important in medical education, little is known about the characteristics of physicians who serve as excellent clinical role models. We therefore conducted a case–control study to identify attributes that distinguish such physicians from their colleagues. Methods We asked members of the internal-medicine house staff at four teaching hospitals to name physicians whom they considered to be excellent role models. A total of 165 physicians named by one or more house-staff members were classified as excellent role models (these served as the case physicians in our study). A questionnaire was sent to them as well as to 246 physicians who had residency-level teaching responsibilities but who were not named (controls). Of these 411 physicians, 341 (83 percent) completed questionnaires while unaware of their case–control status. Results Of the 341 attending physicians who responded, 144 (42 percent) had been identified as excellent role models. Having greater assigned ...

Promotion Criteria for Clinician-educators

OBJECTIVE: Department of medicine chairs have a critical role in the promotion of clinician-educators. Our primary objective was to determine how chairs viewed: 1) the importance of specific areas of clinician-educator performance in promotion decisions; and 2) the importance and quality of information on available measures of performance. A secondary objective was to compare the views of department chairs with those of promotion and tenure committee chairs.METHODS: In October 1997, a questionnaire was mailed to all department chairs in the United States and Canada asking them to rate the importance of 11 areas of clinician-educators’ performance in evaluating them for promotion. We also asked them to rate 36 measures of performance. We compared their responses to a similar 1996 survey administered to promotion committee chairs.RESULTS: One hundred fourteen of 139 department chairs (82%) responded to the survey. When considering a clinician-educator for promotion, department chairs view teaching skills and clinical skills as the most important areas of performance, as did the promotion committee chairs. Of the measures used to evaluate teaching performance, teaching awards were considered most important and rated as a high-quality measure. When evaluating a clinician-educator’s clinical skills, peer and trainee evaluation were considered as the most important measures of performance, but these were rated low in quality. Patient satisfaction and objective outcome measures also were viewed as important measures that needed improvement. Promotion committee chairs placed more emphasis on productivity in publications and external grant support when compared to department chairs.CONCLUSION: It is reassuring that both department chairs and promotion committee chairs value teaching skills and clinical skills as the most important areas of a clinician-educator’s performance when evaluating for promotion. However, differences in opinion regarding the importance of several performance measures and the need for improved quality measures may represent barriers to the timely promotion of clinician-educators.

Examining what residents look for in their role models

PURPOSE: Identifying positive role models and emulating them is a significant component of medical education. This study sought to determine which characteristics were deemed most important by residents regarding their physician role models. METHOD: a 50-item questionnaire about role models was developed and pilot tested. The questionnaire was then administered in the spring of 1994 to 230 residents in various specialty programs at McGill University. RESULTS: A total of 195 residents (85%) responded. Most of the residents (144, 74%) were satisfied with the proportions of positive role models in their current residency training programs. Clinical skills, personality, and teaching ability were rated the three most important factors in selecting a staff physician as a role model. When the residents were asked to recall the positive role models encountered while in medical school, attending physicians in internal medicine received the highest scores. CONCLUSION: Knowing what residents look for in their role models should help to identify which staff physicians are excellent role models. These physicians should be selected to spend more time with medical students and residents, and they should be rewarded for improving medical education.

Predictive validity evidence for medical education research study quality instrument scores: Quality of submissions to JGIM's medical education special issue

BackgroundDeficiencies in medical education research quality are widely acknowledged. Content, internal structure, and criterion validity evidence support the use of the Medical Education Research Study Quality Instrument (MERSQI) to measure education research quality, but predictive validity evidence has not been explored.ObjectiveTo describe the quality of manuscripts submitted to the 2008 Journal of General Internal Medicine (JGIM) medical education issue and determine whether MERSQI scores predict editorial decisions.Design and ParticipantsCross-sectional study of original, quantitative research studies submitted for publication.MeasurementsStudy quality measured by MERSQI scores (possible range 5–18).ResultsOf 131 submitted manuscripts, 100 met inclusion criteria. The mean (SD) total MERSQI score was 9.6 (2.6), range 5–15.5. Most studies used single-group cross-sectional (54%) or pre-post designs (32%), were conducted at one institution (78%), and reported satisfaction or opinion outcomes (56%). Few (36%) reported validity evidence for evaluation instruments. A one-point increase in MERSQI score was associated with editorial decisions to send manuscripts for peer review versus reject without review (OR 1.31, 95%CI 1.07–1.61, p = 0.009) and to invite revisions after review versus reject after review (OR 1.29, 95%CI 1.05–1.58, p = 0.02). MERSQI scores predicted final acceptance versus rejection (OR 1.32; 95% CI 1.10–1.58, p = 0.003). The mean total MERSQI score of accepted manuscripts was significantly higher than rejected manuscripts (10.7 [2.5] versus 9.0 [2.4], p = 0.003).ConclusionsMERSQI scores predicted editorial decisions and identified areas of methodological strengths and weaknesses in submitted manuscripts. Researchers, reviewers, and editors might use this instrument as a measure of methodological quality.

A Systematic Review of Teamwork Training Interventions in Medical Student and Resident Education

BackgroundTeamwork is important for improving care across transitions between providers and for increasing patient safety.ObjectiveThis review’s objective was to assess the characteristics and efficacy of published curricula designed to teach teamwork to medical students and house staff.DesignThe authors searched MEDLINE, Education Resources Information Center, Excerpta Medica Database, PsychInfo, Cumulative Index of Nursing and Allied Health Literature, and Scopus for original data articles published in English between January 1980 and July 2006 that reported descriptions of teamwork training and evaluation results.MeasurementsTwo reviewers independently abstracted information about curricular content (using Baker’s framework of teamwork competencies), educational methods, evaluation design, outcomes measured, and results.ResultsThirteen studies met inclusion criteria. All curricula employed active learning methods; the majority (77%) included multidisciplinary training. Ten curricula (77%) used an uncontrolled pre/post design and 3 (23%) used controlled pre/post designs. Only 3 curricula (23%) reported outcomes beyond end of program, and only 1 (8%) >6weeks after program completion. One program evaluated a clinical outcome (patient satisfaction), which was unchanged after the intervention. The median effect size was 0.40 (interquartile range (IQR) 0.29, 0.61) for knowledge, 0.38 (IQR 0.32, 0.41) for attitudes, 0.41 (IQR 0.35, 0.49) for skills and behavior. The relationship between the number of teamwork principles taught and effect size achieved a Spearman’s correlation of .74 (p = .01) for overall effect size and .64 (p = .03) for median skills/behaviors effect size.ConclusionsReported curricula employ some sound educational principles and appear to be modestly effective in the short term. Curricula may be more effective when they address more teamwork principles.

Resident Research and Scholarly Activity in Internal Medicine Residency Training Programs

OBJECTIVES: 1) To describe how internal medicine residency programs fulfill the Accreditation Council for Graduate Medical Education (ACGME) scholarly activity training requirement including the current context of resident scholarly work, and 2) to compare findings between university and nonuniversity programs.DESIGN: Cross-sectional mailed survey.SETTING: ACGME-accredited internal medicine residency programs.PARTICIPANTS: Internal medicine residency program directors.MEASUREMENTS: Data were collected on 1) interpretation of the scholarly activity requirement, 2) support for resident scholarship, 3) scholarly activities of residents, 4) attitudes toward resident research, and 5) program characteristics. University and nonuniversity programs were compared.MAIN RESULTS: The response rate was 78%. Most residents completed a topic review with presentation (median, 100%) to fulfill the requirement. Residents at nonuniversity programs were more likely to complete case reports (median, 40% vs 25%; P=.04) and present at local or regional meetings (median, 25% vs 20%; P=.01), and were just as likely to conduct hypothesis-driven research (median, 20% vs 20%; P=.75) and present nationally (median, 10% vs 5%; P=.10) as residents at university programs. Nonuniversity programs were more likely to report lack of faculty mentors (61% vs 31%; P<.001) and resident interest (55% vs 40%; P=.01) as major barriers to resident scholarship. Programs support resident scholarship through research curricula (47%), funding (46%), and protected time (32%).CONCLUSIONS: Internal medicine residents complete a variety of projects to fulfill the scholarly activity requirement. Nonuniversity programs are doing as much as university programs in meeting the requirement and supporting resident scholarship despite reporting significant barriers.

Faculty Development in Teaching Skills: An Intensive Longitudinal Model

Although reflection contributes to the personal growth of clinician–educators and is important for effective teaching, few teaching skills programs report its use. The Johns Hopkins Faculty Development Program in Teaching Skills, first implemented in 1987 as a theoretically grounded, longitudinal model for faculty development of clinician–educators, comprises a set of conditions intended to promote reflective learning. This paper describes the program and reports evaluation results for 98 participants and a comparison group of 112 nonparticipants between 1988 and 1996. Participants met with facilitators weekly for nine months for 3.5 hours, in stable groups of four to six individuals. Educational methods used across seven content areas emphasized relationships and collaboration, and included information provision, experiential learning with reflection, and personal awareness sessions. A pre–post evaluation design with comparison group measured changes in self-assessed teaching and professional skills, teaching enjoyment, and learning effectiveness. A post-only evaluation design appraised overall program quality, educational methods, facilitation, learning environment, and perceived impact of participation. Program participants had significantly greater pre–post-change scores than nonparticipants for all 14 outcomes (p < .05). Multiple regression modeling indicated that program participation was associated with pre–post improvement in all outcomes except administration skills, controlling for all participant and nonparticipant baseline characteristics (p < .05). All measured programmatic characteristics were highly rated by participants. Experiential methods with reflection were rated significantly higher than information-provision and personal awareness sessions (p < .001). Evaluation results demonstrate a positive impact of this alternative approach to faculty development on clinician–educator perceptions of their attitudes and behaviors towards learners and colleagues.

Stories From Early-Career Women Physicians Who Have Left Academic Medicine: A Qualitative Study at a Single Institution

Purpose The number of women in academic medicine has steadily increased, although gender parity still does not exist and women leave academics at somewhat higher rates than men. The authors investigated the reasons why women leave careers in academic medicine. Method Semistructured, one-on-one interviews were conducted in 2007–2008 with 20 women physicians who had left a single academic institution to explore their reasons for opting out of academic careers. Data analysis was iterative, and an editing analysis style was used to derive themes. Results A lack of role models for combining career and family responsibilities, frustrations with research (funding difficulties, poor mentorship, competition), work–life balance, and the institutional environment (described as noncollaborative and biased in favor of male faculty) emerged as key factors associated with a decision to leave academic medicine for respondents. Faced with these challenges, respondents reevaluated their priorities and concluded that a discrepancy existed between their own and institutional priorities. Many respondents expressed divergent views with the institutional norms on how to measure success and, as a consequence, felt that they were undervalued at work. Conclusions Participants report a disconnection between their own priorities and those of the dominant culture in academic medicine. Efforts to retain women faculty in academic medicine may include exploring the aspects of an academic career that they value most and providing support and recognition accordingly.

Active bed management by hospitalists and emergency department throughput.

Context Can hospitalists help decrease crowding in emergency departments? Contribution This prepost case study describes a quality-improvement partnership between hospitalists and a university-affiliated emergency department. A hospitalist regularly visited the emergency department, assessed inpatient bed availability, and helped triage admitted patients to particular units. After implementing the program, the average time that admitted patients spent in the emergency department decreased from 458 to 360 minutes. The percentage of hours that the emergency department had to divert ambulances because of crowding and lack of intensive care unit beds decreased by 6% and 27%, respectively. Implication A hospitalist-led bed management program improved emergency department throughput and ambulance-diversion status. The Editors The Institute of Medicines 2006 report, Hospital-Based Emergency Care: At the Breaking Point, is explicitthere is a crisis in U.S. emergency departments (1). Ninety-one percent of emergency departments are crowded beyond capacity (1). Emergency department crowding often results in ambulance diversion: the practice of redirecting ambulances destined for a crowded emergency department to another facility. Diverting ambulances prolongs the lead time until therapy can be initiated and has been associated with increased mortality rates (2). In 2003, ambulance diversion occurred nationwide at the rate of 1 ambulance every minute (3). The primary cause of emergency department crowding is inpatient boarding, that is, holding admitted patients until a hospital bed becomes available. This procedure not only reduces patient satisfaction but also may negatively affect patient outcomes and quality measures (48). Most of the 12 recommendations in the Institute of Medicines report concentrated on factors within emergency departments and ways in which emergency departments interface with the larger health care system. However, 1 strategy focused on hospital processes and efficiency as a way to ameliorate crowding (1). Hospitalist physician groups, internists specializing in the care of hospitalized patients, are now ubiquitous (9). By the nature of their work in coordinating patient care from admission through discharge, hospitalists are uniquely positioned to effectuate efficiency. Our group of hospitalists partnered with the emergency department to address the problem of crowding in our emergency department. We describe the effect of our hospitalist-run service called active bed management. The primary objective of this service was to facilitate the safe transfer of patients from the emergency department to the appropriate inpatient clinical setting. Methods Setting and Design This study took place at Johns Hopkins Bayview Medical Center, a 335-bed university-affiliated medical center in Baltimore, Maryland. The emergency department is a designated level-II center for adult trauma, adult burn, and primary stroke. With capacity for 30 primary treatment rooms, the emergency department registered 54607 visits in the fiscal year ending June 2007. Historically, approximately 25% of the patients registered in the emergency department are admitted, which forms 61% of the hospitals total admissions. Roughly 75% of department of medicine admissions come from the emergency department, totaling approximately 9700 patients annually. The hospitalist division had 14.7 full-timeequivalent physician faculty, 3.0 nurse practitioners, and 4.6 physician assistants at the time of the study. In Maryland, the controlling authority for emergency medical services is the Maryland Institute for Emergency Medical Services Systems. It has defined 2 levels of ambulance diversion. First, an emergency department is put on yellow alert when experiencing a temporary overwhelming overload such that priority II or III patients may not be managed safely. During this period, the Emergency Department requests that absolutely no priority II or priority III patients be transported to their facility. Second, red alert is the designation used when a hospital does not have any electrocardiography-monitored or critical care beds available. During red alert, patients who are likely to require this type of care are not to be transported to the emergency department; instead they are taken to the next closest appropriate hospital (10). These distinct alerts can be invoked separately in coordination with Maryland Institute for Emergency Medical Services Systems, which keeps a record of all alerts for all institutions in Maryland. Using a prepost design, we compared the relevant institution-level clinical data from the intervention period (November 2006 to February 2007) with data from the control period (November 2005 to February 2006) (Figure 1). This study was exempt by the institutional review board. Figure 1. Study flow diagram. JHBMC = Johns Hopkins Bayview Medical Center. Active Bed Management Intervention Before active bed management, the emergency department assigned patients who were admitted to 1 of 5 department of medicine admission services (cardiac intensive care unit [ICU]; medical ICU; and cardiology, pulmonary, and general medicine units). For all units except the general medicine unit, once the department of medicine house officer or a physician assistant was informed of the proposed admission by emergency department personnel, they were expected to evaluate the patient in the emergency department and initiate the transfer to the assigned hospital unit. For the general medicine unit, patient assignments were communicated from the emergency department through a page to a triage physician (hospitalists from 8 a.m. to 8 p.m. and house officers overnight), and once accepted, transfers from the emergency department to the medical floor occurred without in-person evaluation by the department of medicine. Active bed management, done in 12-hour shifts, is coordinated and staffed solely by the hospitalist service 24 hours a day, 7 days a week. All hospitalists in the division rotate through the active bed management role, and the active bed management physician is freed from all other clinical care duties so that his or her only clinical responsibility is facilitation of the active bed management processes. Active bed management was strategically designed around 3 fundamental elements: proactive management of department of medicine resources, evaluation and assignment of all departmental admissions, and mobilization of additional resources by the bed director. Proactive Management of Department of Medicine Resources The active bed management hospitalist assesses bed availability in real time for 2 ICUs (12 beds each), the intermediate care unit (3 beds), 2 subspecialty units (cardiac and pulmonary), and the 4 large general medicine units. These continuous assessments are designed to identify potential resource shortages, such as limited ICU beds, before they occur. Assessments are done through collaboration with unit-specific attending physicians, nursing supervisors, and charge nurses in real time, as well as through twice-daily prediversion rounds in the ICUs. Prediversion rounds provide the ICU teams with information on hospital bed status and identify patients who can be downgraded from critical care status and transferred to nonintensive care settings. Prediversion rounds also serve to collect accurate bed information to allow collaboration between the active bed management hospitalist and emergency department physician on patient flow. Evaluation and Assignment of New Admissions to Department of Medicine Inpatient Clinical Settings The active bed management hospitalist makes collaborative triage decisions about the optimal clinical setting for each patient who requires admission through consultation with all admitting physicians (predominantly emergency department physicians) initially by telephone. Pertinent clinical data are documented on a triage template, and the hospitalist then decides about the need to evaluate selected emergency department patients directly. Authority to make determinations on the assignment of patients to beds in the various services in the department of medicine has been granted to the active bed management hospitalist by the department chairman. Once the hospitalist accepts the admission, the emergency department attending writes brief admitting orders from preexisting order sets. Non-ICU admissions are transferred to the inpatient floor as soon as a bed is available. The receiving medical teams are notified about patients on initial triage and on their arrival to the inpatient unit. Intensive care unit admissions are transferred to the unit no longer than 90 minutes after the disposition decision has been made. This brief period allows ICU teams time to ready themselves and stabilize other patients (if necessary) while facilitating the timely transfer of critically ill patients out of the emergency department. Role of the Bed Director The bed director position was created as part of this intervention to support the active bed management hospitalists. The bed director is the hospitalist leader on call (either division chief or associate division chief). The active bed management hospitalist notifies the bed director if the hospital is put on red or yellow alert, if an alert seems to be looming, or if emergency department throughput for admitted patients is long and resultant crowding is occurring. The bed director has the authority to activate additional resources, both internal and external, to the department of medicine to address such issues in real time. Some resources available to the bed director to shorten delays in throughput and prevent ambulance diversion include calling in additional hospitalists, redirecting admissions to departments outside of medicine, and assigning medical admissions to nondepartment of medicine inpatient beds (where they will be cared for by the hospitalists). The Johns Hopkins