Sitting at the Bedside: Patient and Internal Medicine Trainee Perceptions

BackgroundSitting at the bedside may strengthen physician–patient communication and improve patient experience. Yet despite the potential benefits of sitting, hospital physicians, including resident physicians, may not regularly sit down while speaking with patients.ObjectiveTo examine the frequency of sitting by internal medicine residents (including first post-graduate year [PGY-1] and supervising [PGY-2/3] residents) during inpatient encounters and to assess the association between patient-reported sitting at the bedside and patients’ perceptions of other physician communication behaviors. We also assessed residents’ attitudes towards sitting.DesignIn-person survey of patients and email survey of internal medicine residents between August 2019 and January 2020.ParticipantsPatients admitted to general medicine teaching services and internal medicine residents at The Johns Hopkins Hospital.Main MeasuresPatient-reported frequency of sitting at the bedside, patients’ perceptions of other communication behaviors (e.g., checking for understanding); residents’ attitudes regarding sitting.Key ResultsOf 334 eligible patients, 256 (76%) completed a survey. Among these 256 respondents, 198 (77%) and 166 (65%) reported recognizing the PGY-1 and PGY-2/3 on their care team, respectively, for a total of 364 completed surveys. On most surveys (203/364, 56%), patients responded that residents “never” sat. Frequent sitting at the bedside (“every single time” or “most of the time,” together 48/364, 13%) was correlated with other positive behaviors, including spending enough time at the bedside, checking for understanding, and not seeming to be in a rush (p < 0.01 for all). Of 151 residents, 77 (51%) completed the resident survey; 28 of the 77 (36%) reported sitting frequently. The most commonly cited barrier to sitting was that chairs were not available (38 respondents, 49%).ConclusionsPatients perceived that residents sit infrequently. However, sitting was associated with other positive communication behaviors; this is compatible with the hypothesis that promoting sitting could improve overall patient perceptions of provider communication.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07231-4.     

Resident Satisfaction with Continuity Clinic and Career Choice in General Internal Medicine

Background

The quality of the continuity clinic experience for internal medicine (IM) residents may influence their choice to enter general internal medicine (GIM), yet few data exist to support this hypothesis.

Objective

To assess the relationship between IM residents’ satisfaction with continuity clinic and interest in GIM careers.

Design

Cross-sectional survey assessing satisfaction with elements of continuity clinic and residents'' likelihood of career choice in GIM.

Participants

IM residents at three urban medical centers.

Main Measures

Bivariate and multivariate associations between satisfaction with 32 elements of outpatient clinic in 6 domains (clinical preceptors, educational environment, ancillary staff, time management, administrative, personal experience) and likelihood of considering a GIM career.

Key Results

Of the 225 (90 %) residents who completed surveys, 48 % planned to enter GIM before beginning their continuity clinic, whereas only 38 % did as a result of continuity clinic. Comparing residents’ likelihood to enter GIM as a result of clinic to likelihood to enter a career in GIM before clinic showed that 59 % of residents had no difference in likelihood, 28 % reported a lower likelihood as a result of clinic, and 11 % reported higher likelihood as a result of clinic. Most residents were very satisfied or satisfied with all clinic elements. Significantly more residents (p ≤ 0.002) were likely vs. unlikely to enter GIM if they were very satisfied with faculty mentorship (76 % vs. 53 %), time for appointments (28 % vs. 11 %), number of patients seen (33 % vs. 15 %), personal reward from work (51 % vs. 23 %), relationship with patients (64 % vs. 42 %), and continuity with patients (57 % vs. 33 %). In the multivariate analysis, being likely to enter GIM before clinic (OR 29.0, 95 % CI 24.0–34.8) and being very satisfied with the continuity of relationships with patients (OR 4.08, 95 % CI 2.50–6.64) were the strongest independent predictors of likelihood to enter GIM as a result of clinic.

Conclusions

Resident satisfaction with most aspects of continuity clinic was high; yet, continuity clinic had an overall negative influence on residents’ attitudes toward GIM careers. Targeting resources toward improving ambulatory patient continuity, workflow efficiency and increasing pre-residency interest in primary care may help build the primary care workforce.Key Words: medical education—career choice, medical education—graduate, primary care, ambulatory medicine     

The Effect of Physician Continuity on Diabetic Outcomes in a Resident Continuity Clinic

BACKGROUND  Conflicting data exists regarding the effect of continuity on diabetes care. Resident physicians frequently treat patients with diabetes in their continuity clinics; however, maintaining continuity in a resident clinic can be very challenging. OBJECTIVE  To determine if resident continuity is associated with improvement in diabetic outcomes (HgA1c, LDL, blood pressure) in a resident clinic. DESIGN AND SETTING  Retrospective analysis of data obtained from a medical record review of diabetic patients seen in a resident physician clinic. MEASUREMENTS  We measured continuity, using the Usual Provider of Continuity Index (UPC) for residents and faculty preceptors. We measured changes in HgA1c, LDL, and blood pressure over a 3-year period. Using repeated measures analysis of variance (ANOVA), we assessed the relationship between UPC and change in these diabetic outcomes. RESULTS  The resident UPC was 0.43, and the faculty preceptor UPC was 0.76. The overall change in HgA1c was -0.3. There was a statistically significant relationship between improvement in HgA1c and resident UPC (p = 0.02), but not faculty preceptor UPC. There was no association between resident or faculty preceptor continuity and change in LDL or blood pressure. CONCLUSION  This study showed a link between resident continuity and improvement in glycemic control in diabetic patients. Resident physicians have a greater opportunity to develop a personal relationship with their patients. This interpersonal continuity may be of benefit in patients with illnesses that requires a significant amount of self-management behaviors. Medical training programs should focus efforts on improving continuity in resident primary care clinics.     

Effect of Resident Gender and Surname Origin on Clinical Load: Observational Cohort Study in an Internal Medicine Continuity Clinic

BackgroundStudies show patients may have gender or racial preferences for physicians.ObjectiveTo determine the degree to which physicians’ gender and name characteristics influenced physician clinical load in medical practice, including patient panel size and percent of slots filled.DesignObservational cohort study of a continuity clinic site in Rochester, MN, from July 1, 2015 to June 30, 2017 (“historical” period) and July 1, 2018 to January 30, 2020 (“contemporary” period).ParticipantsInternal medicine resident physicians.Main MeasuresResident gender, name, and race came from residency management system data. Panel size, percent of appointment slots filled (“slot fill”), panel percent female, and panel percent non-White came from the electronic health record. Multivariable linear regression models calculated beta estimates with 95% confidence intervals and R² for the impact of physician gender, surname origin, name character length, and name consonant-to-vowel ratio on each outcome, adjusting for race and year of residency.Key ResultsOf the 307 internal medicine residents, 122 (40%) were female and 197 (64%) were White. Their patient panels were 51% female (SD 16) and 74% White (SD 6). Female gender was associated with a 5.3 (95% CI 2.7–7.9) patient increase in panel size and a 1.5% (95% CI −0.6 to 3.7) increase in slot fill. European, non-Hispanic surname was associated with a 5.3 (95% CI 2.6–7.9) patient increase in panel size and a 4.3 percent (95% CI 2.1–6.4) increase in slot fill. Race and other name characteristics were not associated with physician clinical load. From the historical to contemporary period, the influence of name characteristics decreased from 9 to 4% for panel size and from 15 to 5% for slot fill.ConclusionsFemale gender and European, non-Hispanic surname origin are associated with increased physician clinical load—even more than race. While these disparities may have serious consequences, they are also addressable.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06296-x) contains supplementary material, which is available to authorized users.KEY WORDS: gender, surname, race, physician, patient     

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

BACKGROUND  

Many 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.     

Determinants of Resident Satisfaction with Patients in Their Continuity Clinic

The purpose of this study was to identify what patient and physician factors influence resident satisfaction with patient encounters in a continuity clinic setting. Resident satisfaction was assessed from postencounter questionnaires completed by 68 internal medicine residents regarding 979 patient encounters. We found that residents were more satisfied with patients diagnosed with general medical problems than with patients diagnosed with pain and psychiatric disorders. First-year residents were less satisfied with patients diagnosed with pain and psychiatric disorders than second- and third-year residents. However, this dissatisfaction with seeing patients with pain or psychiatric disorders lessened as continuity of care was enhanced.     

Medical Student Perceptions of Cost-Conscious Care in an Internal Medicine Clerkship: A Thematic Analysis

Background

Although as much as 87 % of all healthcare spending is directed by physicians, studies have demonstrated that they lack knowledge about the costs of medical care. Similarly, learners have not traditionally received instruction on cost-conscious care.

Objective

To examine medical students'' perceptions of healthcare delivery as it relates to cost consciousness

Design

Retrospective qualitative analysis of medical student narratives

Participants

Third-year medical students during their inpatient internal medicine clerkship

Main Measures

Students completed a reflective exercise wherein they were asked to describe a scenario in which a patient experienced lack of attention to cost-conscious care, and were asked to identify solutions and barriers. We analyzed these reflections to learn more about students’ awareness and perceptions regarding the practice of cost-conscious care within our medical center.

Key Results

Eighty students submitted the assignment between July and December 2012. The most common problems identified included unnecessary tests and treatments (n = 69) and duplicative tests and treatments (n = 20.) With regards to solutions, students described 82 scenarios, with 125 potential solutions identified. Students most commonly used discussion with the team (speak up, ask why) as the process they would use (n = 28) and most often wanted to focus lab testing (n = 38) as the intervention. The most common barriers to high-value care included increased time and effort (n = 19), ingrained practices (n = 17), and defensive medicine or fear of missing something (n = 18.)

Conclusions

Even with minimal clinical experience, medical students were able to identify instances of lack of attention to cost-conscious care as well as potential solutions. Although students identified the hierarchy in healthcare teams as a potential barrier to improving high value care, most students stated they would feel comfortable engaging the team in discussion. Future efforts to empower learners at all levels to question value decisions and to develop and implement solutions may result in improved healthcare.     

Resident Duty Hours: A Survey of Internal Medicine Program Directors

INTRODUCTION

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new Common Program Requirements to regulate duty hours of resident physicians, with three goals: improved patient safety, quality of resident education and quality of life for trainees. We sought to assess Internal Medicine program director (IMPD) perceptions of the 2011 Common Program Requirements in July 2012, one year following implementation of the new standards.

METHODS

A cross-sectional study of all IMPDs at ACGME-accredited programs in the United States (N?=?381) was performed using a 32-question, self-administered survey. Contact information was identified for 323 IMPDs. Three individualized emails were sent to each director over a 6-week period, requesting participation in the survey. Outcomes measured included approval of duty hours regulations, as well as perceptions of changes in graduate medical education and patient care resulting from the revised ACGME standards.

RESULTS

A total of 237 surveys were returned (73 % response rate). More than half of the IMPDs (52 %) reported “overall” approval of the 2011 duty hour regulations, with greater than 70 % approval of all individual regulations except senior resident daily duty periods (49 % approval) and 16-hour intern shifts (17 % approval). Although a majority feel resident quality of life has improved (55 %), most IMPDs believe that resident education (60 %) is worse. A minority report that quality (8 %) or safety (11 %) of patient care has improved.

CONCLUSION

One year after implementation of new ACGME duty hour requirements, IMPDs report overall approval of the standards, but strong disapproval of 16-hour shift limits for interns. Few program directors perceive that the duty hour restrictions have resulted in better care for patients or education of residents. Although resident quality of life seems improved, most IMPDs report that their own workload has increased. Based on these results, the intended benefits of duty hour regulations may not yet have been realized.