Teaching residents to care for vulnerable populations in the outpatient setting

Residency programs have an obligation to teach house officers to care for vulnerable populations. Such populations consist of those whom physicians tend to consider undesirable as patients, and thus who often lack adequate care, because they cannot pay for medical services, because they have medical problems that are difficult to manage, or because they have characteristics giving them low social status. The authors identify and discuss key aspects of learning to care for such populations. These aspects include obtaining appropriate experience caring for disadvantaged patients, developing sensitivity to pertinent sociocultural issues, exploring biases, acquiring relevant special skills, studying epidemiology of diseases in specific vulnerable groups, and learning about health care financing and health policy. Measures to help residents obtain more satisfaction from caring for vulnerable patients are among additional topics discussed.     

Systematic outpatient screening for the elderly: care of the vulnerable elderly practice improvement module to assess resident care of older adults

OBJECTIVES: To determine the feasibility of using the American Board of Internal Medicine Care of the Vulnerable Elderly Practice Improvement Module (CoVE PIM) in an internal medicine residency program and to assess aggregate resident documentation of geriatric screening in continuity clinics. DESIGN: Needs assessment chart review for single‐site pre‐/postintervention study. SETTING: Internal medicine resident primary care continuity clinics. PARTICIPANTS: Thirty‐seven postgraduate year (PGY)‐1 and PGY‐2 internal medicine residents. MEASUREMENTS: Completion rate and time of CoVE PIM chart review, CoVE PIM user difficulty, and aggregate percentage of charts documenting geriatric screening measures. RESULTS: Sixty‐five percent of residents completed the CoVE PIM in an average of 47 minutes (range 30–90 minutes); 72% of resident surveys rated the CoVE PIM as easy to use. Residents demonstrated very good documentation of chronic medical conditions, smoking status, height, weight, and blood pressure and poor documentation of falls and fall risk, hearing assessment, postural hypotension, balance, rigidity, bradykinesia, home safety assessment, seat belt counseling, code status, and surrogate decision‐maker. CONCLUSION: The CoVE PIM can be used to assess aggregate resident performance of geriatric screening measures. In resident clinics, general adult screening performed by nurses is well documented, whereas geriatric‐specific screening performed by physicians is poorly documented.     

Curriculum for ambulatory care training in medical residency Rationale, attitudes, and generic proficiencies

This paper provides a foundation for establishing curricula to train medical residents in ambulatory care. To do so, it first presents reasons that curricula are needed in this area. It then delineates attitudes and proficiencies (knowledge and skills) that such curricula should be designed to instill. Finally, it briefly discusses implications for curriculum development. Extensive tables are provided, including detailed lists of generic proficiencies that residents should attain. Among realms in which these proficiencies lie are organizing the ambulatory care encounter, using interpersonal skills, gathering information through physical examination and other means, obtaining and employing clinically useful knowledge, documenting the encounter, and planning and coordinating care. The paper notes that planning for the discharge of patients from the hospital can contribute to obtaining proficiencies important in ambulatory care.     

Proficiency of internal medicine residents in outpatient care of patients with HIV infection

To determine internal medicine residents’ knowledge of HIV care, the authors conducted a survey of residents from four internal medicine programs in the San Francisco Bay area. On a knowledge test, the mean score was 42.4/55, 77% correct. The residents performed relatively worse on questions regarding didanosine and zalcitabine, tuberculosis prophylaxis, and risk of cervical neoplasia in HIV-infected women. Predictors of greater knowledge were specific residency program, higher postgraduate year, primary care residency track, and more extensive HIV experience. Primary care internal medicine residencies and programs with more exposure to HIV patients are most effective in producing knowledgeable residents. Supported by the AIDS Clinical Research Center, University of California San Francisco, VA Medical Center (141A), 4150 Clement Street, San Francisco, CA 94121; and National Institute of Mental Health Grant: MH44045 (Dr. Cooke). Dr. Bindman is a Robert Wood Johnson Generalist Physician Faculty Scholar. This research was conducted, in part, while Dr. Schultz was a fellow in general internal medicine and clinical epidemiology in the Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California.     

Brief report: Utilizing an audiotape for outpatient preceptor faculty development

BACKGROUND: Faculty development for busy and geographically dispersed ambulatory preceptors is a difficult task for course directors. PURPOSE: A faculty development audiotape intended for playing in the preceptor's car was created. The feasibility of this form of faculty development was tested in this pilot study. METHODS: A short audiotape, focusing on strategies for the provision of independence to students in the office setting, was made and distributed to all preceptors of students taking a fourth-year required clerkship in ambulatory medicine. Preceptor behavior was reported by students on postclerkship evaluations before and after tape distribution. RESULTS: In the year before tape distribution, 21% of evaluations indicated a lack of independence on the part of the student, compared with 14% in the year following the intervention (P=.03). There was no regression of behavior among preceptors already providing independence. Among the preceptors initially identified as not following recommendations for student independence, the percentage of evaluations indicating a lack of independence went from 72% preintervention to 42% postintervention (P<.001). CONCLUSIONS: A short audiotape is a novel form of faculty development, which was acceptable to preceptors and may influence teaching behavior in the desired manner.     

Patient satisfaction in resident and attending ambulatory care clinics

OBJECTIVE: To measure and compare patient satisfaction with care in resident and attending physician internal medicine ambulatory care clinics. DESIGN: A cross-sectional survey using a questionnaire derived from the Visit-Specific Satisfaction Questionnaire (VSQ) and Patient Satisfaction Index (PSI) distributed from March 1998 to May 1998. SETTING: Four clinics based at a university teaching hospital and the associated Veterans' Affairs (VA) hospital. PARTICIPANTS: Two hundred eighty-eight patients of 76 resident and 25 attending physicians. RESULTS: Patients of resident physicians at the university site were more likely to be African American, male, have lower socioeconomic status and have lower physical and mental health scores on the Short Form-12 than patients of university attendings. Patients of resident and attending physicians at the VA site were similar. In multivariate analyses, patients of university attending physicians were more likely to be highly satisfied than patients of university residents on the VSQ-Physician (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.6 to 7.8) and the PSI-Physician (OR, 10.1; 95% CI, 3.7 to 27.4) summary scores. Differences were not seen on the summary scores at the VA site. Two individual items displayed significant differences between residents and attendings at both sites: "personal manner (courtesy, respect, sensitivity, friendliness) of the doctor" (P 相似文献   

Will commercial managed care patients accept residents as their primary care providers?

We conducted a telephone survey of patients in a university-based medical practice to determine if there was a difference across payer class in patients' willingness to have supervised housestaff physicians function as their primary care providers. Overall, commercial managed care patients were more likely to object to seeing housestaff physicians than were Medicaid or Medicare patients (50% vs 32% or 23%, respectively). However, prior outpatient care by a resident physician significantly increased patient willingness to be cared for by a resident. This effect of prior care by a resident was noted in the managed care as well as the Medicaid and Medicare populations. Although there may have been self-selection, our data demonstrate that a significant proportion of managed care patients who have had residents as their primary care providers are amenable to continuing this practice.     

Structure and quality of outpatient care for people living with an HIV infection

Policy-makers and clinicians are faced with a gap of evidence to guide policy on standards for HIV outpatient care. Ongoing debates include which settings of care improve health outcomes, and how many HIV-infected patients a health-care provider should treat to gain and maintain expertise. In this article, we evaluate the studies that link health-care facility and care provider characteristics (i.e., structural factors) to health outcomes in HIV-infected patients. We searched the electronic databases MEDLINE, PUBMED, and EMBASE from inception until 1 January 2015. We included a total of 28 observational studies that were conducted after the introduction of combination antiretroviral therapy in 1996. Three aspects of the available research linking the structure to quality of HIV outpatient care were evaluated: (1) assessed structural characteristics (i.e., health-care facility and care provider characteristics); (2) measures of quality of HIV outpatient care; and (3) reported associations between structural characteristics and quality of care. Rather than scarcity of data, it is the diversity in methodology in the identified studies and the inconsistency of their results that led us to the conclusion that the scientific evidence is too weak to guide policy in HIV outpatient care. We provide recommendations on how to address this heterogeneity in future studies and offer specific suggestions for further reading that could be of interest for clinicians and researchers.     

The association between residents’ work-rounds styles and the process and outcome of medical care

Objective: To determine whether the manner in which residents conduct work rounds is associated with the adequacy of their care processes and the outcomes of their patients. Methods: Two types of data were collected: time and motion data for residents (n=12) during work rounds, and clinical and outcome data for the patients they cared for during the observation period (n=211). Five residents were classified as data gatherers because they spent twice as much time gathering clinical data about their patients as they spent engaging in other activities. Three physicians blinded to the resident’s identity rated the quality of the care process and assessed the frequency of undesirable events occurring during the stay and after discharge. Results: A data-gathering style was associated with higher quality of care as judged by both process and outcomes. The data gatherers were more likely to comply with the “stability of medications before discharge” criterion (86% of the data gatherers’ cases vs 73% of others’, p=0.07), and their patients were less likely to have unanticipated problems, in that fewer required calls from nurses (20% vs 37%, p<0.01) and visits by on-call housestaff (33% vs 50%, p=0.01). The data gatherers’ patients were less likely to be readmitted within 30 days (14% vs 38%, p<0.01). Conclusions: A data-gathering work-rounds style is associated with better process and outcome. Residency programs should provide formal instruction to trainees in the conduct of work rounds. Received from the General Medicine Section, Veterans Affairs Medical Center, and Baylor College of Medicine, Houston, Texas. Presented in poster form at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 28–30, 1993. Supported in part by the Houston Center for Quality of Care and Utilization Studies, a Veterans Affairs Health Services Research and Development Field Program.     

Communication breakdown in the outpatient referral process

OBJECTIVE: To evaluate primary care and specialist physicians' satisfaction with interphysician communication and to identify the major problems in the current referral process. DESIGN: Surveys were mailed to providers to determine satisfaction with the referral process; then patient-specific surveys were e-mailed to this group to obtain real-time referral information. SETTING: Academic tertiary care medical center. PARTICIPANTS: Attending-level primary care physicians (PCPs) and specialists. MEASUREMENTS AND MAIN RESULTS: The response rate for mail surveys for PCPs was 57% and for specialists was 51%. In the mail survey, 63% of PCPs and 35% of specialists were dissatisfied with the current referral process. Respondents felt that major problems with the current referral system were lack of timeliness of information and inadequate referral letter content. Information considered important by recipient groups was often not included in letters that were sent. The response rate for the referral specific e-mail surveys was 56% for PCPs and 53% for specialists. In this e-mail survey, 68% of specialists reported that they received no information from the PCP prior to specific referral visits, and 38% of these said that this information would have been helpful. In addition, four weeks after specific referral visits, 25% of PCPs had still not received any information from specialists. CONCLUSIONS: Substantial problems were present in the referral process. The major issues were physician dissatisfaction, lack of timeliness, and inadequate content of interphysician communication. Information obtained from the general survey and referral-specific survey was congruent. Efforts to improve the referral system could improve both physician satisfaction and quality of patient care.     

Integrating general medicine and rheumatology training in the outpatient setting

The authors describe a primary care-based educational and practice model that integrates general medicine resident education in outpatient rheumatology with specialty fellowship training. Compared with the use of traditional specialty clinics, the model provides better access and service to patients and more appropriate training for residents. Revenues from clinical service delivered by facultysupervised residents and fellows support 80% of the operating costs and educational activities of the model. The conceptual framework for the model reconciles the educational goals and practice philosophies of general medicine and specialty training and is applicable to training in other predominantly outpatient specialty areas.     

A comparison of the methods and criteria used by traditional and primary care internal medicine programs to select residents

OBJECTIVE: To determine whether there are differences in the methods and criteria used by primary care and traditional internal medicine programs to select first-year residents. DESIGN: A questionnaire was sent to primary care and traditional internal medicine program directors, who were asked to rank in importance ten documents of an applicant’s file and to score the relative importance, on a scale of −5 to +5, of 21 candidate traits of four types: academic, demographic, personal, and career goal. SETTING: Programs at institutions (n=54) that have categorical residency programs in both traditional and primary care internal medicine. PARTICIPANTS: Of 108 questionnaires, the overall response rate was 81%, with 40 pairs (74%) of matched respondents. Seventy-two percent of the responding institutions were university- administered. RESULTS: Primary care and traditional programs use similar methods to process applicants, rank similarly ten documents in an applicant’s file, and value academic success during the clinical years as the most important candidate trait. Compared with traditional tracks, primary care tracks place greater emphasis on a candidate’s career goals and select for candidates planning to pursue primary care careers (3.9±1.4 vs 0.9±1.5, p<0.001), enter practice (1.4±1.5 vs 0.1±1.2, p<0.001), or serve medically indigent populations (2.7±1.5 vs 1.2±1.2, p<0.001). Primary care programs rate negatively candidates who intend to subspecialize, whereas traditional programs view them almost neutrally (−1.8±2.2 vs 0.5±1.5, p<0.001). CONCLUSION: Primary care and traditional track internal medicine programs use similar methods to select residents and both rank academic achievement during the clinical years as a candidate’s most important attribute. However, only primary care programs strongly select for candidates on the basis of their career plans and in particular prefer candidates who are committed to pursuing primary care careers and serving the medically indigent. Received from the Division of General Internal Medicine and Primary Care, Department of Medicine, University of California, Irvine, California. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 29-May 1, 1992. Supported in part by a grant from the U.S. Public Health Service (2 D28 PE19154).     

Medical errors related to discontinuity of care from an inpatient to an outpatient setting

OBJECTIVE: To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes. PATIENTS: Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge. DESIGN: Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors. MEASUREMENTS: Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit. MAIN RESULTS: Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations. CONCLUSION: We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.     

Oral versus written feedback in medical clinic

OBJECTIVE: To determine whether residents perceived oral, face-to-face feedback about their continuity clinic performance as better than a similar, written version. DESIGN: Single-blind, randomized controlled trial. SETTING: Two university-based, internal medicine residency clinics. PARTICIPANTS: All 68 internal medicine and combined program (medicine-pediatrics, medicine-psychiatry, medicine-neurology, and preliminary year) residents and their clinic preceptors. MEASUREMENTS AND MAIN RESULTS: Residents at each program were separately randomized to oral or written feedback sessions with their clinic preceptors. The oral and written sessions followed similar, structured formats. Both groups were later sent questionnaires about aspects of the clinic. Sixty-five (96%) of the residents completed the questionnaire. Eight of the 19 questions dealt with aspects of feedback. A feedback scale was developed from the survey responses to those eight questions (α=.86). There were no significant differences in the responses to individual questions or in scale means (p>.20) between the two feedback groups. When each university was analyzed separately, one had a higher scale mean (3.10 vs 3.57, p=.047), but within each university, there were no differences between the oral and written feedback groups (p>.20). CONCLUSIONS: No differences were observed between the oral and written feedback groups. In attempting to provide better feedback to their residents, medical educators may better apply their efforts to other aspects, such as the frequency of their feedback, rather than the form of its delivery. Supported by the Department of Medicine, West Virginia University. Presented in part at the Society of General Internal Medicine annual meeting, 1995.     

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Accurately recognizing the learning goals of trainees should enhance teachers' effectiveness. We sought to determine how commonly such recognition occurs and whether it improves residents' satisfaction with the teaching interaction. In a cross-sectional survey of 97 internal medicine residents and 42 ambulatory clinic preceptors in five ambulatory care clinics in Washington and Oregon, we systematically sampled 236 dyadic teaching interactions. Each dyad participant independently indicated the residents' perceived learning needs from a standardized list. Overall, the preceptors' recognition of the residents' learning needs, as measured by percentage of agreement between preceptors and residents on the learning topics, was modest (kappa 0.21, p =.02). The percentage of agreement for all topics was 43%, ranging from 8% to 66%. Greater time pressures were associated with lower agreement (38% vs 56% for the highest and lowest strata of resident-reported time pressure; 15% vs 43% for highest and lowest strata of preceptor-reported time pressure). Agreement increased as the number of sessions the pair had worked together increased (62% for pairs with > 20 vs 17% for pairs with 0 previous sessions). Satisfaction with teaching encounters was high (4.5 on a 5-point scale) and unrelated to the degree of agreement ( p =.92). These findings suggest that faculty development programs should emphasize precepting skills in recognizing residents' perceived learning needs and that resident clinics should be redesigned to maximize preceptor-resident continuity and minimize time pressure.     

Update on teaching in the long-term care setting

Since the advent of the teaching nursing home, made formal in the 1980s, long-term care has been used to teach geriatric medicine. Despite this, national surveys have indicated a need for more training during residency to facilitate the appropriate care for the frail long-term care patient population. In addition to medical knowledge, the long-term care site is appropriate for teaching the Accreditation Council of Graduate Medical Education's core competencies of "practice-based learning and improvement," "interpersonal and communication skills," and "systems-based practice." Program planners should emphasize opportunities for students to demonstrate their skill in one of these competencies.