William A. Norcross

Remediation of the Deficiencies of Physicians Across the Continuum From Medical School to Practice: A Thematic Review of the Literature

Despite widespread endorsement of competency-based assessment of medical trainees and practicing physicians, methods for identifying those who are not competent and strategies for remediation of their deficits are not standardized. This literature review describes the published studies of deficit remediation at the undergraduate, graduate, and continuing medical education levels. Thirteen studies primarily describe small, single-institution efforts to remediate deficient knowledge or clinical skills of trainees or below-standard-practice performance of practicing physicians. Working from these studies and research from the learning sciences, the authors propose a model that includes multiple assessment tools for identifying deficiencies, individualized instruction, deliberate practice followed by feedback and reflection, and reassessment. The findings of the study reveal a paucity of evidence to guide best practices of remediation in medical education at all levels. There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance.

Toward meeting the challenge of physician competence assessment: the University of California, San Diego Physician Assessment and Clinical Education (PACE) Program.

Physician competence and performance problems contribute to medical errors and substandard health care quality. Assessment of the clinical competence of practicing physicians, however, is challenging. Although physician competence assessment undoubtedly does take place at the local level (e.g., hospital, medical group), it is difficult to objectively assess a partner, colleague, or friend. Moreover, the methodologies used and the outcomes are necessarily veiled by peer review statutes. Consequently, there is a need for regional or national assessment centers with the knowledge, skill, and experience to perform clinical competence assessments on individual physicians and provide or direct remediation, when appropriate. The University of California, San Diego (UCSD) Physician Assessment and Clinical Education (PACE) Program was founded at the UCSD School of Medicine in 1996 for this purpose. From inception in 1996 through the first quarter of 2009, 867 physicians have participated in the UCSD PACE Program. The PACE Program is divided into two components. Phase I includes two days of multilevel, multimodal testing, and Phase II is a five-day, preceptor-based formative assessment program taking place in the residency program of the physicians specialty. From July 2002 through December 2005, a study of 298 physician participants of the UCSD PACE Program was conducted. The future of the comprehensive assessment of practicing physicians depends on (1) development and standardization of instruments, techniques, and procedures for measuring competence and performance, including in-practice measures, (2) collaborative networking of assessment programs, (3) cost control, and (4) continued development of remedial measures that correspond to assessment findings.

Code Lavender: Cultivating Intentional Acts of Kindness in Response to Stressful Work Situations

Context: Providing healthcare can be stressful. Gone unchecked, clinicians may experience decreased compassion, and increased burnout or secondary traumatic stress. Code Lavender is designed to increase acts of kindness after stressful workplace events occur. Objective/Intervention: To test the feasibility of providing Code Lavender. Hypotheses: After stressful events in the workplace, staff will provide, receive, and recommend Code Lavender to others. The provision of Code Lavender will improve Professional Quality of Life Scale (ProQoL) scores, general job satisfaction, and feeling cared for in the workplace. Method/Sample: Pilot program testing and evaluation. Staff and physicians on four hospital units were informed of the Code Lavender kit availability, which includes words of comfort, chocolate, lavender essential oil, and employee health referral information. Feasibility data and ProQoL scores were collected at baseline and three months. Results: At baseline, 48% (n = 164) reported a stressful event at work in the last three months. Post‐intervention, 51% reported experiencing a stressful workplace event, with 32% receiving a Code Lavender kit from their co‐workers as a result (n = 83). Of those who received the Code Lavender intervention; 100% found it helpful, and 84% would recommend it to others. No significant changes were demonstrated before and after the intervention in ProQoL scores or job satisfaction, however the emotion of feeling cared‐for improved. Conclusions: Results warrant continuation and further dissemination of Code Lavender. Investigators have received requests to expand the program implying positive reception of the intervention. Additional interventions are needed to overcome workplace stressors. A more intense peer support program is being tested.

Urinary gnathostomiasis in a Laotian refugee.

Gnathostoma spinigerum is an uncommonly encountered parasite, even in a practice such as ours, which hosts a Travelers Clinic and provides care for a relatively large Southeast Asian population. Gnathostomiasis is most commonly reported in Asia, particularly Thailand and J apan.1 N onetheless, gnathostomiasis is a potentially serious, even life-threatening, parasitosis that can be seen in any primary care setting that provides health care for Southeast Asian refugee populations. As of 30 September 1990, the Southeast Asian refugee population of the United States was estimated to total 957,100, with refugees in every state and large populations in California (378,500), Texas (71,800), Washington (44,900), Minnesota (34,900), and New York (34,300).2 Consequently, although this parasite is reportedly rare in the United States, family physicians could well encounter Southeast Asian refugee patients and should be familiar with the clinical presentations of this parasite. We present a case of urinary gnathostomiasis in a Laotian refugee. To our knowledge, this case is only the second reported in the United States. The first case of urinary gnathostomiasis in the United States was reported in 1984.3

Update on the UC San Diego Healer Education Assessment and Referral (HEAR) Program

Burnout, depression and suicide are rampant amongst health care professionals. Current evidence shows the problem is worsening. In the aftermath of physician suicides, the Physician Wellbeing Commi...

Testing of a Caregiver Support Team

Context: Healthcare clinicians often endure stress over long periods of time. The burden of witnessing death and disability, complex work duties, long and irregular hours, the threat of errors, and tensions between colleagues result in emotional strain, anxiety, depression, burnout and in the worst case: suicide. The Caregiver Support Team was designed to provide emotional first aid to clinicians in the healthcare environment in the moment of need and triage those who would benefit from ongoing care. Objective/Intervention: To test the feasibility of providing a Caregiver Support Team to provide emotional first aid in the workplace. This project is an extension of our previously reported Code Lavender initiative. Hypotheses: After stressful events in the workplace, staff will provide, receive, and recommend the Caregiver Support Team to others. The Caregiver Support Team will be used and accepted by clinicians, improve Professional Quality of Life Scale (ProQoL) scores, general job satisfaction and feeling cared for in the workplace. Method/Sample: We describe a pilot program. Following the completion of a Code Lavender pilot, physicians and staff on 4 hospital units provided nominations for peer supporters: someone they would trust in a time of emotional need. These peer supporters were provided 8 hours of training by a psychologist and voluntarily sought to find those in the workplace who were affected by workplace stress and provide emotional support. Feasibility data and ProQoL scores were collected at baseline and 3 months. Results: At baseline, 59% (n = 44) reported symptomatic stress caused by the workplace. Main causes of stress were emotional responses of patients/families, disputes with colleagues, and negative clinical outcomes. Colleagues were reported as the most frequently used source of support following workplace stress. A Caregiver Support Team intervention was received by 40% of respondents; 100% found it helpful and 100% would recommend it to others. No significant changes were demonstrated before and after the intervention in ProQoL Scores, or job satisfaction. The emotion of feeling cared‐for improved. Staff spontaneously requested emotional debriefings through peer supporters. One suicide was prevented. Conclusions: The Caregiver Support Team was positively received. The organization received budgetary support from our hospital to disseminate the program system‐wide. Additional interventions are needed to overcome the root cause of workplace stressors. A formal link between Risk Management is being developed to identify cases which warrant emotional (vs. clinical only or both) debriefing/group processing.

Value of General Medical Knowledge Examinations in Performance Assessment of Practicing Physicians With Potential Competence and Performance Deficiencies.

Introduction: Problems with a physicians performance may arise at any point during their career. As such, there is a need for effective, valid tools and processes to accurately assess and identify deficiencies in competence or performance. Although scores on multiple-choice questions have been shown to be predictive of some aspects of physician performance in practicing physicians, their relationship to overall clinical competence is somewhat uncertain particularly after the first 10 years of practice. As such, the purpose of this study was to examine how a general medical knowledge multiple-choice question examination is associated with a comprehensive assessment of competence and performance in experienced practicing physicians with potential competence and performance deficiencies. Methods: The study included 233 physicians, of varying specialties, assessed by the University of California, San Diego Physician Assessment and Clinical Education Program (PACE), between 2008 and 2012, who completed the Post-Licensure Assessment System Mechanisms of Disease (MoD) examination. Logistic regression determined if the examination score significantly predicted passing assessment outcome after correcting for gender, international medical graduate status, certification status, and age. Results: Most physicians (89.7%) received an overall passing assessment outcome on the PACE assessment. The mean MoD score was 66.9% correct, with a median of 68.0%. Logistic regression (P = .038) was significant in indicating that physicians with higher MoD examination scores had an increased likelihood of achieving a passing assessment outcome (odds ratio = 1.057). Discussion: Physician MoD scores are significant predictors of overall physician competence and performance as evaluated by PACE assessment.