Stewart F. Babbott

Electronic medical records and physician stress in primary care: results from the MEMO Study.

BACKGROUND Little has been written about physician stress that may be associated with electronic medical records (EMR). OBJECTIVE We assessed relationships between the number of EMR functions, primary care work conditions, and physician satisfaction, stress and burnout. DESIGN AND PARTICIPANTS 379 primary care physicians and 92 managers at 92 clinics from New York City and the upper Midwest participating in the 2001-5 Minimizing Error, Maximizing Outcome (MEMO) Study. A latent class analysis identified clusters of physicians within clinics with low, medium and high EMR functions. MAIN MEASURES We assessed physician-reported stress, burnout, satisfaction, and intent to leave the practice, and predictors including time pressure during visits. We used a two-level regression model to estimate the mean response for each physician cluster to each outcome, adjusting for physician age, sex, specialty, work hours and years using the EMR. Effect sizes (ES) of these relationships were considered small (0.14), moderate (0.39), and large (0.61). KEY RESULTS Compared to the low EMR cluster, physicians in the moderate EMR cluster reported more stress (ES 0.35, p=0.03) and lower satisfaction (ES -0.45, p=0.006). Physicians in the high EMR cluster indicated lower satisfaction than low EMR cluster physicians (ES -0.39, p=0.01). Time pressure was associated with significantly more burnout, dissatisfaction and intent to leave only within the high EMR cluster. CONCLUSIONS Stress may rise for physicians with a moderate number of EMR functions. Time pressure was associated with poor physician outcomes mainly in the high EMR cluster. Work redesign may address these stressors.

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.

Ambulatory-Based Education in Internal Medicine: Current Organization and Implications for Transformation. Results of A National Survey of Resident Continuity Clinic Directors

BACKGROUNDMany have called for ambulatory training redesign in internal medicine (IM) residencies to increase primary care career outcomes. Many believe dysfunctional, clinic environments are a key barrier to meaningful ambulatory education, but little is actually known about the educational milieu of continuity clinics nationwide.OBJECTIVEWe wished to describe the infrastructure and educational milieu at resident continuity clinics and assess clinic readiness to meet new IM-RRC requirements.DESIGNNational survey of ACGME accredited IM training programs.PARTICIPANTSDirectors of academic and community-based continuity clinics.RESULTSTwo hundred and twenty-one out of 365 (62%) of clinic directors representing 49% of training programs responded. Wide variation amongst continuity clinics in size, structure and educational organization exist. Clinics below the 25th percentile of total clinic sessions would not meet RRC-IM requirements for total number of clinic sessions. Only two thirds of clinics provided a longitudinal mentor. Forty-three percent of directors reported their trainees felt stressed in the clinic environment and 25% of clinic directors felt overwhelmed.LIMITATIONSThe survey used self reported data and was not anonymous. A slight predominance of larger clinics and university based clinics responded. Data may not reflect changes to programs made since 2008.CONCLUSIONSThis national survey demonstrates that the continuity clinic experience varies widely across IM programs, with many sites not yet meeting new ACGME requirements. The combination of disadvantaged and ill patients with inadequately resourced clinics, stressed residents, and clinic directors suggests that many sites need substantial reorganization and institutional commitment.New paradigms, encouraged by ACGME requirement changes such as increased separation of inpatient and outpatient duties are needed to improve the continuity clinic experience.

Can the Targeted Use of a Discharge Pharmacist Significantly Decrease 30-Day Readmissions?:

Background The prevalence and cost of hospital readmissions have gained attention. The ability to identify patients at high risk for hospital readmission has implications for quality and costs of care. Medication errors have been shown to increase the risk for readmission. Objective To study the impact of a pharmacist-based predischarge medication reconciliation and counseling program on 30-day readmission rates and determine whether polypharmacy and problem medications are important screening criteria. Methods A prospective, nonrandomized cohort study performed at a single medical-surgical unit with telemetry capability at a single academic medical center. The participants were 729 patients, aged 18 years and older, who were discharged between July 1 and October 29, 2010. The intervention was pharmacist medication reconciliation and counseling based on a screening tool. The primary outcome was 30-day readmission rate. Secondary outcomes were the presence of polypharmacy and problem medications and their relationship with observed 30-day readmission rate, including calculation of a problem med/polypharmacy score. Results The pharmacy review group (n = 537) had a lower 30-day readmission rate than the group receiving usual care (n = 192) (16.8% vs 26.0%; odds ratio [OR] 0.572; 95% CI, 0.387-0.852; P = .006). Polypharmacy, defined as either 5 or more or 10 or more scheduled medications, alone and in combination with at least one problem medication had higher 30-day readmission rates. A score of no factors present exhibited good negative predictive value. Conclusions Medication reconciliation and counseling by a pharmacist reduced the 30-day readmission rate. Polypharmacy and problem medications appear to have value individually and together. A pharmacist, guided by a screening tool in predischarge medication reconciliation, is one option to effectively reduce 30-day readmissions.

Redesigning the practice model for general internal medicine. A proposal for coordinated care: A policy monograph of the Society of General Internal Medicine

General Internal Medicine (GIM) faces a burgeoning crisis in the United States, while patients with chronic illness confront a disintegrating health care system. Reimbursement that rewards using procedures and devices rather than thoughtful examination and management, plus onerous administrative burdens, are prompting physicians to pursue specialties other than GIM. This monograph promotes 9 principles supporting the concept of Coordinated Care—a strategy to sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the longitudinal care of adult patients with acute and chronic illness. This approach supplements and extends the concept of the Advanced Medical Home set forth by the American College of Physicians. Specific components of Coordinated Care include clinical support, information management, and access and scheduling. Success of the model will require changes in the payment system that fairly reimburse physicians who provide leadership to teams that deliver high quality, coordinated care.General Internal Medicine (GIM) faces a burgeoning crisis in the United States, while patients with chronic illness confront a disintegrating health care system. Reimbursement that rewards using procedures and devices rather than thoughtful examination and management, plus onerous administrative burdens, are prompting physicians to pursue specialties other than GIM. This monograph promotes 9 principles supporting the concept of Coordinated Care—a strategy to sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the longitudinal care of adult patients with acute and chronic illness. This approach supplements and extends the concept of the Advanced Medical Home set forth by the American College of Physicians. Specific components of Coordinated Care include clinical support, information management, and access and scheduling. Success of the model will require changes in the payment system that fairly reimburse physicians who provide leadership to teams that deliver high quality, coordinated care.

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.

AAIM Report on Master Teachers and Clinician Educators Part 4: Faculty Role and Scholarship

AIM Report on Master Teachers and Clinician ducators Part 4: Faculty Role and Scholarship tephen A. Geraci, MD, Harry Hollander, MD, Stewart F. Babbott, MD, Raquel Buranosky, MD, onna R. Devine, BS, Regina A. Kovach, MD, Lee Berkowitz, MD Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Mississippi School of edicine, Jackson; Division of Infectious Diseases, Department of Medicine, University of California, San Francisco; Division of General and Geriatric Medicine, Department of Medicine, University of Kansas School of Medicine, Kansas ity; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Penn; Department of edicine, University of Washington; Division of General Internal Medicine, Department of Medicine, Southern Illinois niversity School of Medicine, Springfield; Department of Medicine, University of North Carolina at Chapel Hill, Chapel ill.

Are we making progress in medical education

Scholarship in medical education consists of a rich compilation of studies and innovations designed to enhance our understanding of the process and content of education, contributing to and enhancing the training of physicians and their practice of high-quality patient care. Viewed through the lens of the Society of General Internal Medicine (SGIM) Residency Reform Task Force Report,1 the 29 reports in this issue advance our understanding of the educational mission and vision for a broad range of topics.

AAIM Report on Master Teachers and Clinician Educators Part 3: Finances and Resourcing

AIM Report on Master Teachers and Clinician ducators Part 3: Finances and Resourcing tephen A. Geraci, MD, Donna R. Devine, BS, Stewart F. Babbott, MD, Harry Hollander, MD, aquel Buranosky, MD, Regina A. Kovach, MD, Lee Berkowitz, MD Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Mississippi School of edicine, Jackson; Department of Medicine, University of Washington, Seattle; Division of General and Geriatric edicine, Department of Medicine, University of Kansas School of Medicine, Kansas City; Division of Infectious Diseases, epartment of Medicine, University of California, San Francisco; Division of General Internal Medicine, Department of edicine, University of Pittsburgh, Pa; Division of General Internal Medicine, Department of Medicine, Southern Illinois niversity School of Medicine, Springfield; Department of Medicine, University of North Carolina at Chapel Hill.

“May We Live in Interesting Times”—Society of General Internal Medicine Clinician-educators Respond to New Challenges in Graduate Medical Education

July 1, 2003 marked a watershed moment in graduate medical education in this country. New interns entered residency programs transformed by two sweeping reforms from the Accreditation Council for Graduate Medical Education (ACGME), which acted to raise our professions accountability for training new physicians. First, the ACGME approved duty hours standards for all accredited programs.1 This regulation reflects growing concerns, dating back to the Libby Zion case in 1984, about the effects of fatigue on resident well-being and patient safety. The ACGME first responded in the 1990s with loosely enforced work hours limitations, which varied widely by specialty. As many programs failed to comply (30% of reviewed internal medicine programs cited in 19992), the public outcry grew louder and was heard in the Occupational Safety and Health Administration and in the halls of Congress.3 By this time, stakeholders could cite a growing body of scientific evidence linking long work hours to poorer performance and increased burnout among residents.4 With this backdrop, the ACGME imposed (and is beginning to enforce) an 80-hour per week limit, 1 day off in 7, and relief after a 24-hour shift plus 6 hours for transition. Second, the ACGME “outcomes project” changed the accreditation currency from process and structure to outcome.5 Program directors must now provide more than a schedule of rotations, a written curriculum, and agreements with clinical training venues. They must objectively document that their residents achieve a level of competence in six general dimensions of practice. Two of these, practice-based learning and improvement and systems-based practice, reflect a recent emphasis on evidence-based reflective practice and newer models of team care and disease management. As directors dramatically restructure their programs to comply with these two formidable unfunded mandates, they struggle with many uncertainties.6,7 They can take some lessons from New York State, which has legislated work hours restrictions since 1989.8 And the ACGME “toolbox” provides some guidance in evaluating the six competencies. Nonetheless, many questions remain unanswered. In this issue, educators respond to these challenges with reports of creative studies, innovative curricula, and robust evaluation strategies. Hoellein et al.s study adds to the evidence underpinning the work hours restrictions.9 In this observational study of 646 clinic encounters in a single program, patients were less satisfied with their visits with postcall residents, after adjusting for important confounders. Of note, resident satisfaction did not vary with call status. Wong et al. developed an innovative day-float rotation that responds to both ACGME mandates.10 A senior medical resident joins the postcall team for morning rounds, assists with the daily tasks, and pursues the teams emerging clinical questions. When the day-float rotation was in operation, ward residents worked from 67 to 81 hours per week, compared to 79 to 90 hours prior to implementation. In addition, by keeping a learning portfolio, the day-float resident documents her practice-based learning competency. Day-float residents collected 6.6 and answered 6.1 questions per rotation. We suspect a very low recording rate, however, given studies showing that residents encounter clinical questions at a much higher rate.11 Pinsky and Fryer-Edwards describe their programs experience with a more ambitious program-wide portfolio system, designed to evaluate and promote reflection around all six ACGME competencies.12 They identified five elements that may promote successful implementation, including separate working and performance functions, a supportive climate, skill development in faculty and residents, observing progress over time, and fostering mentoring opportunities. Residents in this program apparently offered little resistance to maintaining portfolios. However, skeptical program directors may require more quantitative feasibility data before asking their busy residents to embrace this extra task. Residents completed quality improvement projects in Ogrinc et al.s innovative practice-based learning and improvement curriculum.13 In a pre-post controlled trial, exposed residents improved their scores on a validated quality improvement knowledge instrument. Furthermore, their project sponsors appreciated the meaningful contributions to care in their clinical venues. Two investigators raised the bar for procedure training, which falls within the “patient care” competency. Smith et al. developed an innovative medical procedure service, which included a web-based component to teach procedural knowledge and 24-hour availability of qualified faculty (hospitalists and intensivists) to teach, supervise, evaluate, and track procedural experience.14 The additional billing revenues partially offset the costs of increased faculty coverage. In a 12-month pilot program, the complication rate was 3.7% over 246 procedures. The pneumothorax rate for thoracenteses was only 3.5%, which compares favorably to a 10.6% rate in a pooled analysis of the literature. Watkins and Moran developed a targeted intervention to train residents in Pap smear sampling, which included a skills workshop with a manikin and peer comparison feedback of adequacy data.15 In a randomized controlled trial, exposed residents were twice as likely to obtain sufficient endocervical cells, adjusting for important confounding variables. On a practical level, competency-based evaluations add a substantial administrative burden to already stressed program leadership and staff. Triola et al. developed a web-based modular evaluation system that generates competency-based, venue-specific, and training level-specific questions for evaluators and customized evaluation reports for residents, faculty, and program directors.16 In their program, evaluation compliance increased from 35% in a paper system to 85% at 10 months after transition to this electronic system. Finally, while investigators often report easily measured endpoints like trainee satisfaction, knowledge, and skills, we are charged to determine “how the design and conduct of medical education programs affect the clinical outcomes produced by doctors.”17 Educators, in this issue, evaluated the impact of educational interventions on trainee performance, such as procedure complications, Pap smear adequacy, and patient satisfaction. Furthermore, the educational activities themselves may add value to clinical care.18 Of course, “this is not the end,” as Churchill said. “It is not even the beginning of the end. But it is, perhaps, the end of the beginning.” The impact of these reforms will play out over many years. Much more research is needed to address lingering questions. For instance, many educators worry about the repercussions of disrupting continuity of care to meet work hours standards. What, then, will be the net effect on quality of care, patient satisfaction, resident education, and resident well-being? What is the ideal resident workweek? And important economic questions should rekindle the debate about GME funding. Will hospitals be able to absorb the “replacement costs” of resident hours and maintain their support of residency programs? Will program faculty be able to fully implement competency-based training, while they receive a shrinking allocation of GME financial support and insufficient academic “credit” for this work? Will researchers be able to advance the lagging educational science, despite extremely limited funding opportunities? We do, indeed, live in interesting times.