Stephen M. Salerno

Faculty Development Seminars Based on the One‐Minute Preceptor Improve Feedback in the Ambulatory Setting

OBJECTIVE: While several models of medical student instruction in the ambulatory setting exist, few have been formally studied. We wished to assess the impact of a faculty development workshop based on the One-Minute Preceptor model on the amount and quality of feedback in the outpatient setting.DESIGN: Ambulatory teaching behaviors were studied during consecutive outpatient precepting sessions before and after 3 faculty development workshops. Student-teacher interactions were assessed using audiotapes of teaching encounters coded through qualitative techniques, and surveys of teacher, learner, and patient satisfaction.SETTING: Ambulatory internal medicine clinic in a tertiary care medical center.PATIENTS/PARTICIPANTS: Nine board-certified internist faculty preceptors and 44 third-year medical students.INTERVENTIONS: Three 90-minute faculty development seminars based on the One-Minute Preceptor teaching model.MEASUREMENTS AND MAIN RESULTS: Ninety-four encounters with 18,577 utterances were recorded, half before and half after the seminars. After the workshops, the proportion of utterances that contained feedback increased from 17% to 22% (P=.09) and was more likely to be specific (9% vs 15%; P=.02). After the workshops, teachers reported that the learning encounters were more successful (P=.03) and that they were better at letting the students reach their own conclusions (P=.001), at evaluating the learners (P=.03), and at creating plans for post-encounter learning (P=.02). The workshops had no effect on the duration of the student-teacher encounter or on student or patient satisfaction with the encounters.CONCLUSIONS: Brief, interactive, faculty development workshops based on the One-Minute Preceptor model of clinical teaching resulted in modest improvements in the quality of feedback delivered in the ambulatory setting.

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.

Standardized Sign-Out Reduces Intern Perception of Medical Errors on the General Internal Medicine Ward

Background: Prior research on reducing variation in housestaff handoff procedures have depended on proprietary checkout software. Use of low-technology standardization techniques has not been widely studied. Purpose: We wished to determine if standardizing the process of intern sign-out using low-technology sign-out tools could reduce perception of errors and missing handoff data. Methods: We conducted a pre–post prospective study of a cohort of 34 interns on a general internal medicine ward. Night interns coming off duty and day interns reassuming care were surveyed on their perception of erroneous sign-out data, mistakes made by the night intern overnight, and occurrences unanticipated by sign-out. Trainee satisfaction with the sign-out process was assessed with a 5-point Likert survey. Results: There were 399 intern surveys performed 8 weeks before and 6 weeks after the introduction of a standardized sign-out form. The response rate was 95% for the night interns and 70% for the interns reassuming care in the morning. After the standardized form was introduced, night interns were significantly (p < .003) less likely to detect missing sign-out data including missing important diseases, contingency plans, or medications. Standardized sign-out did not significantly alter the frequency of dropped tasks or missed lab and X-ray data as perceived by the night intern. However, the day teams thought there were significantly less perceived errors on the part of the night intern (p = .001) after introduction of the standardized sign-out sheet. There was no difference in mean Likert scores of resident satisfaction with sign-out before and after the intervention. Conclusion: Standardized written sign-out sheets significantly improve the completeness and effectiveness of handoffs between night and day interns. Further research is needed to determine if these process improvements are related to better patient outcomes.

Interactive Faculty Development Seminars Improve the Quality of Written Feedback in Ambulatory Teaching

We performed a pre-post study of the impact of three 90-minute faculty development workshops on written feedback from encounters during an ambulatory internal medicine clerkship. We coded 47 encounters before and 43 after the workshops, involving 9 preceptors and 44 third-year students, using qualitative and semiquantitative methods. Postworkshop, the mean number of feedback statements increased from 2.8 to 3.6 statements (P=.06); specific (P=.04), formative (P=.03), and student skills feedback (P=.01) increased, but attitudinal (P=.13) and corrective feedback did not (P=.41). Brief, interactive, faculty development workshops may refine written feedback, resulting in more formative specific written feedback comments.

The impact of oral phenylpropanolamine on blood pressure: a meta-analysis and review of the literature

Oral phenylpropanolamine is commonly used to treat congestion and obesity. Clinicians often wonder what effect it has on blood pressure and whether they are safe in hypertensive patients. The purpose of our systematic review was to assess whether these drugs cause clinically meaningful elevations in pulse or blood pressure. English-language, randomized, placebo-controlled trials of oral phenylpropanolamine in adults with extractable data on pulse or blood pressure were studied. MEDLINE (1966–2003), Embase, the Cohcrane library and reviewed article references were used as sources. Systolic (SBP) and diastolic blood pressure (DBP) and heart rate data were extracted. Additional extracted data included demographics, year, study design, study duration, drug dose and frequency, duration of washout and country. Study quality was assessed using the methods of Jadad and data were synthesized using a random effects model using weighted mean differences. In all, 33 trials reporting 48 treatment arms with 2165 patients were included. Phenylpropanolamine increased SBP 5.5 mmHg (95% CI: 3.1–8.0) and DBP 4.1 mmHg (95% CI: 2.2–6.0) with no effect on pulse. Patients with controlled hypertension were not at greater risk of blood pressure elevation. Immediate release preparations had greater effects on blood pressure than sustained release ones. Higher doses and shorter duration use also caused greater increases. Eighteen studies contained at least one treated subjects having blood pressure elevations ⩾140/90 mmHg, an increase in SBP ⩾15 mmHg or an increase in DBP ⩾10 mmHg. In conclusion, phenylpropanolamine caused a small, but significant increase in systolic blood pressure. The effect was more pronounced with shorter-term administration, higher doses of medication and immediate release formulations.

Disruptions and Satisfaction in Internal Medicine Resident Continuity Clinic Differ Between Inpatient and Outpatient Rotations

Abstract Background: Little is known about whether assignment to simultaneous inpatient and outpatient clinical duties causes disruptions during internal medicine resident continuity clinic and impacts trainee satisfaction. Purpose: Our purpose was to determine whether dual inpatient and continuity clinic responsibilities impact resident stress and document the number, type, and immediacy of interruptions in continuity clinics. Methods: Methods included a prospective 2-residency survey of 70 internal medicine residents performing 240 half-day continuity clinic sessions. Results: More than half (52%) of trainees on inpatient rotations felt pressured to return to their ward duties. Half (50%) of residents thought clinic increased work hours, and the majority (70%) did not think continuity clinic detracted from their education on inpatient or elective rotations. Disturbances were more likely to occur on inpatient rotations (odds ratio 4.52, 95% confidence interval = 2.29-8.92) than on outpatient rotations. The time required to address an interruption was 3.9 ± 4.51 min. Residents thought many (46%) problems addressed during clinic could have waited until clinic completion. Conclusions: Residents on inpatient rotations who were commonly interrupted in clinic felt pressured to return to ward duties and unable to focus on their clinic patients. Internal medicine faculty should modify curriculum to minimize the interference of other duties in resident clinics.