T. S. Caudill

CAN PHYSICIANS IMPROVE PATIENT SATISFACTION WITH LONG WAITING TIMES

The purpose of our study was to determine how time spent with the physician might be related to patient dissatisfaction with their waiting time. During a 2-month period, patients in our internal medicine resident continuity clinic completed a survey assessing their satisfaction with their waiting time and their estimates of their waiting time and time spent with the resident physician. For patients with long waiting times (more than 15 min in the waiting room or more than 10 min in the exam room), patient dissatisfaction with waiting time was associated with a shorter physician visit (48% were dissatisfied if the physician spent less than 15 min vs. 18% if the physician spent more than 15 min with them, p = .03). These data suggest that physicians can mediate the negative effects of long waiting times by spending more time with their patients. Future studies on patient satisfaction should consider this interaction.

Do pressure and fatigue influence resident job performance

Background: Global surveys of residents have consistently identified stress variables as important factors in resident job performance. Aims: Determine whether an association exists between resident stress and job performance. Method: Over a three month period, interns on our inpatient ward services were surveyed regarding their current call schedule, whether their prior nights sleep was sufficient, whether they felt pressed by other commitments, whether they spent enough time teaching medical students and whether they had completed all patient care issues on a given day. Multiple logistic regression was used to assess the association between call status, pressure and sleep adequacy with reported omissions in patient care and adequacy of teaching. Results: In the regression analysis, ratings of high pressure and insufficient sleep but not call status independently predicted outcomes. For example, if an intern felt both pressed and tired, they were over eight times more likely to omit a patient care issue and over four times more likely to report inadequate teaching. Conclusions: Subjective ratings of high pressure and insufficient sleep are associated with poor job performance in medical residents.

Are Continuity Clinic Patients Less Satisfied When Residents Have a Heavy Inpatient Workload

The purpose of this study was to assess the influence of resident nonclinic workload on the satisfaction of continuity clinic patients. Over a 2-month period in 2002, residents and patients were surveyed at the University of Kentucky internal medicine continuity clinic. Residents provided a self-report of their nonclinic workload as light or medium versus heavy or extremely heavy. Patient satisfaction was assessed with a 7-item, 10-point scale with items derived from commonly used patient satisfaction instruments. In 168 patient encounters, patients were significantly less satisfied with their clinic visit if they were seen by a resident who had a heavier workload. In addition, these patients gave significantly lower ratings with regard to the amount of time spent with the patient during the visit, and how well the resident listened and paid attention. Although alternative explanations exist, we propose that heavy hospital workload is associated with decreased patient satisfaction in resident continuity clinic.

Evaluation of a rural-oriented primary care curriculum for internal medicine residents.

No abstract available.

A NUTRITION AND PHYSICAL WELL-BEING WORKSHOP USING STANDARDIZED PATIENTS INCREASES KNOWLEDGE AND IMPROVES SKILLS.: 369

age confirmed that the post-FCM group scored significantly higher than the pre-FCM group. The test group parameter estimate was 4.02 (p , .001). In this model, the step 1 score was also a significant predictor of step 2 score: parameter estimate 0.699 (p , .001). The model’s adjusted R was 0.5375. Conclusions: Both step 1 scores and the FCM course were independent and significant predictors of step 2 performance for medical students. A centrally developed curriculum integrating clinical and basic sciences is feasible for the third year of medical school and is associated with an improvement in standardized testing.

336 ARE WE PREPARING RESIDENTS FOR THE ECONOMIC REALITIES OF MEDICAL PRACTICE

Purpose As the cost of health care continues to rise, cost containment practices have a growing impact on physician ability to survive financially while continuing to provide appropriate patient care. Medical educators have been slow to integrate these issues into medical curricula. This study was conducted to evaluate the frequency with which physicians in practice deal with these issues and how well our program prepares them. Methods Physicians who graduated from our medicine and medicine pediatric residencies from 1995-2005 were surveyed. They were asked to rate on a 5-point Likert scale preparedness (1 = poorly prepared, 5 = very prepared) and frequency of performance (1 = never, 5 = very often) of several skills, including billing and coding and administration/office management. For the purpose of analysis, being well prepared and a skill being frequently performed were considered to be ratings of 4 or 5. Graduates were also asked to list issues with resource allocation they dealt with on a routine basis and their strategies for overcoming these issues. Results There were 112 surveys returned for a response rate of 52%. On the specific item related to billing and coding, 85% of respondents reported that this is a frequent practice and only 24% felt that residency prepared them well. The item regarding administration/office management elicited a similar response; 61% reported frequent practice while only 6% felt their residency prepared them well. The most frequent themes of resource allocation were formulary restrictions and obtaining approval for diagnostic testing or care. The most frequently reported strategies were phone calls and letters to third-party payers. Conclusion At our program, graduates report that they are poorly prepared for some of the business tasks essential to their professional lives. These striking data reinforce the importance of incorporating these issues into medical curricula.

335 DOES A NUTRITION AND PHYSICAL WELL-BEING WORKSHOP USING STANDARDIZED PATIENTS INCREASE KNOWLEDGE AND IMPROVE SKILLS?

Background Only about 20% of Americans consume the recommended proportions of fruits and vegetables and achieve the recommended level of physical activity. Also, only about 40% of patients report receiving dietary or exercise advice from their doctor. Therefore, nutrition and physical well-being (NPWB) knowledge and counseling skills should be part of the medical student curriculum. The purpose of this study is to determine the impact of a NPWB workshop (WS) using standardized patients (SP) on knowledge and clinical skills of third-year medical students. Methods A 4-hour NPWB WS was developed as part of a new curriculum for a required third-year 4-week primary care internal medicine clerkship. The NPWB WS and three other novel WS were randomized for delivery to half of the rotational groups. The NPWB WS incorporates four SP cases representing different clinical challenges (exercise prescription, diabetic dietary counseling, stress reduction strategies, and low-carbohydrate diet counseling). A faculty preceptor facilitates group discussion of sensitive approaches to the problems. Participating students are also provided a 17-page NPWB reference. All students in every rotation group are assigned NPWB readings. At the end of the 4 weeks, all students take a 100-item written exam (seven NPWB questions) and nine-station SP exam (one NPWB station) including a post-SP encounter open-ended written exercise. Scores on the written exam NPWB items, NPWB SP checklist, and NPWB open-ended written exercise of workshop participants and nonparticipants were analyzed with simple means, standard deviations, and multiple regression approaches controlling for USMLE Step 1 scores and preventive care SP station checklist scores. Results The NPWB WS was delivered to 6 of the 12 rotation groups during the 2004-2005 academic year. Forty-nine students participated in the workshop and 48 did not. Workshop participants performed significantly better than nonparticipants on the NPWB written exam items (5.7 6 1.0 vs 4.9 6 1.2, F = 13.9, p < .001) and the post-SP encounter written exercise (86.9% 6 6.7 vs 78.9% 6 5.8, F = 36, p < .001). There was no significant difference (p = .55) between the groups on the SP checklists. Conclusions Students participating in a 4-hour SP workshop exhibit superior NPWB knowledge as assessed by open-ended and multiple-choice questions. NPWB attitudinal and supportive counseling skills are easily integrated into basic interviewing while practice with SPs assists in acquisition of knowledge.

240 WHAT MAKES ATTENDING ROUNDS EDUCATIONAL

Purpose Few studies have examined the content of teaching rounds on general internal medicine ward services. Even less is known about what makes for effective attending teaching rounds with regard to resident and medical student education. We hypothesized that both students and residents would feel that rounds were educational if they were more actively involved. Methods Over a four month period, trained research assistants (second year medical students) observed attending rounds at our university hospital. The research assistants coded the two most dominant activities occurring within each 5-minute interval during rounds with respect to content and involvement. Activities on rounds were conceptualized as involving either teaching, patient care, administrative tasks or dead time. Involvement was coded as to the participation of individual team members: attending physician, upper level resident, interns and students. For the purpose of analysis, each team members involvement was calculated as the percentage of the total rounding time that they were judged to be involved in the discussions. After rounds, the research assistants rated the rounds with regards to teaching quality (1 = poor, 10 = excellent) and the perceived student/resident involvement (1 = not involved, 10 = very involved). Results Overall, 96 different attending rounds were observed. The teaching quality of rounds was judged to be above average with a mean rating of 6.2 ± 2.2. Overall residents were judged to be more involved than students, 8.4 ± 1.7 versus 5.1 ± 2.6. Likewise, examining the percentage of rounds involving different team members, attending physicians were the most involved (accounting for 72% of the interactions on rounds), followed by residents (41%), interns (37%) and finally students (23%). The overall teaching quality as judged by the research assistants was associated with higher rating of perceived student involvement (r = .37, p = .0005) but not with the perception of resident involvement (r = .12, p = .24). Examining the percentage of rounding time involving different team members, research assistants judged rounds to be of higher teaching quality when the attending physicians were less involved (r = -.25, p = .02). Conclusions The majority of teaching rounds are centered on the attending physician with medical students having the lowest involvement of all team members. However, the teaching that occurs on attending rounds is judged to be of higher quality when medical students are more involved and attending physicians are less involved.

Resident recognition of open-angle glaucoma: effects of an educational intervention

To test an educational intervention’s effect on improving detection of glaucoma by direct ophthalmoscopy, 14 medicine residents examined five patients, two with ophthalmoscopic changes of glaucoma and three with normal fundi. The residents observed a standardized slide/narrative educational intervention reviewing glaucomatous ophthalmoscopic changes and then re-examined the same patients eight to 12 weeks later. The intervention’s odds of improving residents’ diagnostic impression were significant (OR=2.2; 95% CI=1.3–36), with significant improvement in sensitivity (p=0.02) and a trend toward improved specificity. These findings confirm that the diagnosis of glaucomatous ocular changes on eye examinations by medicine residents can be improved with a brief educational intervention.