Addressing alcohol use among primary care patients

Objectives: To determine whether rates of addressing alcohol use differed between family medicine and internal medicine residents, and to determine whether attitudes, confidence, and perceptions affected these relationships. Setting: Two university outpatient clinics, one staffed by family medicine and the other by primary care and categorical internal medicine residents. Design: Cross-sectional study of consecutive patients who had been followed by second- and third-year residents for at least one year. Measurements: Alcohol abuse was determined using the Michigan Alcoholism Screening Test (MAST), with a score a 5 considered positive. Rates of addressing alcohol use in the preceding year were determined by patient report and chart review. Attitudes were assessed using the Substance Abuse Attitude Survey (SAAS). Results: 334 patients of 49 residents completed the MAST. Rates of alcoholism among the patient groups were: family medicine, 8.3%; primary care, 29.1%; and categorical medicine, 18.0% (p<0.001). Screening behavior varied by type of residency: 47% of the family medicine, 71% of the primary care, and 65% of the categorical residents’ patients reported being asked about alcohol use in the preceding year (p<0.001); chart documentation was present for 15% of the family medicine, 38% of the primary care, and 24% of the categorical residents’ patients (p<0.001). Perceived prevalence of alcohol abuse, confidence in intervening, and several scales on the SAAS were related to residency type and to addressing alcohol use, but controlling for these variables did not affect the association between residency type and either patient report or chart documentation of screening. Conclusion: Rates of addressing alcohol use differed for internal medicine and family medicine residents, but were not due to differences in resident perceptions and attitudes. Supported in part by the Center for Substance Abuse Prevention, grant number AA07526.     

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     

Alumni perspectives comparing a general internal medicine program and a traditional medicine program

Objective:To evaluate a primary care internal medicine curriculum, the authors surveyed four years (1983–1986) of graduates of the primary care and traditional internal medicine residency programs at their institution concerning the graduates’ preparation. Design:Mailed survey of alumni of a residency training program. Setting:Teaching hospital alumni. Subjects/methods:Of 91 alumni of an internal medicine training program for whom addresses had been found, 82 (90%) of the residents (20 primary care and 62 traditional) rated on a five-point Likert scale 82 items for both adequacy of preparation for practice and importance of training. These items were divided into five groups: traditional medical disciplines (e.g., cardiology), allied disciplines (e.g., orthopedics), areas related to medical practice (e.g., patient education), basic skills and knowledge (e.g., history and physical), and technical procedures. Main results:Primary care residents were more likely to see themselves as primary care physicians versus subspecialists (84% versus 45%). The primary care graduates felt significantly better prepared in the allied disciplines and in areas related to medical practice (p<0.01). There was no significant difference overall in perceptions of preparation in the traditional medical disciplines, basic skills and knowledge, and procedures. The same results were obtained when the authors looked only at graduates from the two programs who spent more than 50% of their time as primary care physicians versus subspecialists. There was no significant difference between the two groups in the perceived importances of these areas to current practice. Conclusions:These results suggest that the primary care curriculum has prepared residents in areas particularly relevant to primary care practice. Additionally, these individuals feel as well prepared as do their colleagues in the traditional medical disciplines, basic skills and knowledge, and procedural skills. Received from the Division of General Internal Medicine, Brown University Program in Medicine, and the Rhode Island Hospital, Providence, Rhode Island. Dr. Kiel is a Henry J. Kaiser Family Foundation Faculty Scholar in general internal medicine. Address correspondence and reprint requests to General Internal Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.     

High-Value,Cost-Conscious Care Attitudes in the Graduate Medical Education Learning Environment: Various Stakeholder Attitudes That Residents Misjudge

BackgroundTraining residents in delivering high-value, cost-conscious care (HVCCC) is crucial for a sustainable healthcare. A supportive learning environment is key. Yet, stakeholders’ attitudes toward HVCCC in residents’ learning environment are unknown.ObjectiveWe aimed to measure stakeholders’ HVCCC attitudes in residents’ learning environment, compare these with resident perceptions of their attitudes, and identify factors associated with attitudinal differences among each stakeholder group.DesignWe conducted a cross-sectional survey across the Netherlands between June 2017 and December 2018.ParticipantsParticipants were 312 residents, 305 faculty members, 53 administrators, and 1049 patients from 66 (non)academic hospitals.Main MeasuresRespondents completed the Maastricht HVCCC Attitude Questionnaire (MHAQ), containing three subscales: (1) high-value care, (2) cost incorporation, (3) perceived drawbacks. Additionally, resident respondents estimated the HVCCC attitudes of other stakeholders, and answered questions on job demands and resources. Univariate and multivariate analyses were used to analyze data.Key ResultsAttitudes differed on all subscales: faculty and administrators reported more positive HVCCC attitudes than residents (p ≤ 0.05), while the attitudes of patients were less positive (p ≤ 0.05). Residents underestimated faculty’s (p < 0.001) and overestimated patients’ HVCCC attitudes (p < 0.001). Increasing age was, among residents and faculty, associated with more positive attitudes toward HVCCC (p ≤ 0.05). Lower perceived health quality was associated with less positive attitudes among patients (p < 0.001). The more autonomy residents perceived, the more positive their HVCCC attitude (p ≤ 0.05).ConclusionsAttitudes toward HVCCC vary among stakeholders in the residency learning environment, and residents misjudge the attitudes of both faculty and patients. Faculty and administrators might improve their support to residents by more explicitly sharing their thoughts and knowledge on HVCCC and granting residents autonomy in clinical practice.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06261-8) contains supplementary material, which is available to authorized users.KEY WORDS: attitudes, graduate medical education, high-value, cost-conscious care, learning environment, job characteristics     

Self-Confidence in and Perceived Utility of the Physical Examination: A Comparison of Medical Students,Residents, and Faculty Internists

BACKGROUND AND OBJECTIVES Little is known about the differences in attitudes of medical students, Internal Medicine residents, and faculty Internists toward the physical examination. We sought to investigate these groups’ self-confidence in and perceived utility of physical examination skills. DESIGN AND PARTICIPANTS Cross-sectional survey of third- and fourth-year medical students, Internal Medicine residents, and faculty Internists at an academic teaching hospital. MEASUREMENTS Using a 5-point Likert-type scale, respondents indicated their self-confidence in overall physical examination skill, as well as their ability to perform 14 individual skills, and how useful they felt the overall physical examination, and each skill, to be for yielding clinically important information. RESULTS The response rate was 80% (302/376). The skills with overall mean self-confidence ratings less than “neutral” were interpreting a diastolic murmur (2.9), detecting a thyroid nodule (2.8), and the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature (2.5). No skills had a mean utility rating less than neutral. The skills with the greatest numerical differences between mean self-confidence and perceived utility were distinguishing between a mole and melanoma (1.5), detecting a thyroid nodule (1.4), and interpreting a diastolic murmur (1.3). Regarding overall self-confidence, third-year students’ ratings (3.3) were similar to those of first-year residents (3.4; p = .95) but less than those of fourth-year students (3.8; p = .002), upper-level residents (3.7; p = .01), and faculty Internists (3.9; p < .001). CONCLUSIONS Self-confidence in the physical exam does not necessarily increase at each stage of training. The differences found between self-confidence and perceived utility for a number of skills suggest important areas for educational interventions.     

Health and health care among housestaff in four U.S. internal medicine residency programs

BACKGROUND: Although there have been many studies of the health care services that resident physicians provide, little is known about the health care services they receive. OBJECTIVE: To describe residents’ perceptions of the health care they receive. DESIGN: Anonymous mailed survey. SUBJECTS: All 389 residents in four U.S. categorical internal medicine training programs. MAIN RESULTS: Three hundred sixteen residents responded (83%). In aggregate, 116 (37%) reported having no primary care physician, and 36 (12%) reported that they are their own primary care physician. These figures varied substantially across the four programs. Most residents reported receiving basic screening and preventive services; however, their attitudes toward their health and health care differed across postgraduate level, gender, and program. Many residents reported that their long and unpredictable hours interfered with their ability to schedule clinician visits, that their health had declined because of residency, that programs and other residents were unsupportive of residents’ health care needs, and that residency raised special issues of privacy that limited access to health care. CONCLUSIONS: Despite high rates of receipt of preventive services, these internal medicine residents identified several barriers that limited their access to health care. Program directors should explore these barriers and, at the same time, reevaluate the messages being sent to resident physicians about maintaining their health and health care. This work was supported in part by SmithKline Beecham and the Greenwall Foundation. Dr. Asch is a Department of Veterans Affairs Health Services Research and Development Senior Research Associate.     

Late-life depression in primary care

OBJECTIVE: To discover primary care physicians’ attitudes toward their abilities to detect and treat depression in the elderly. DESIGN: A self-administered questionnaire sent to 1,000 primary care physicians in the state of Michigan. SETTING: The survey was sent to physicians who practice general internal medicine or family medicine. PARTICIPANTS: The questionnaire was sent to 500 MD and 500 DO physicians; equal representation was given to general internal medicine and family medicine. Of all 1,000 physicians, 60% (n=604) responded, 51% (n=309) were MD’s, 48% (n=295) were DO’s, 41% (n=245) were general internists, and 59% (n=359) were family medicine physicians. MEASUREMENTS AND MAIN RESULTS: Despite positive attitudes about their skills for detecting and treating depression in the elderly, only one quarter of the respondents routinely used a screening tool in practice. Forty-one percent of all physicians were not aware of depression practice guidelines. Family physicians were more confident about their treatment skills than were general internists (85% vs 50%;x ²=11.42,p≤.003). Male physicians more often endorsed pharmacologic treatment, while female physicians more frequently used counseling and exercise techniques to treat depressed older patients. Half of all physicians felt knowledgeable about community resources to treat older depressed patients. CONCLUSIONS: This survey identified several perceived needs for future targeted interventions: (1) additional Agency for Health Care Policy and Research guideline exposure for all primary care physicians, (2) targeted counseling skill intervention for male physicians and medication management for female physicians, and (3) additional continuing medical education intervention for practicing general internists. Further research is needed to correlate physician attitudes with ensuing behaviors to fully appreciate the nature of late-life depression treatment within the primary care arena. Received from the Department of Psychiatry, Michigan State University, East Lansing. Funded in full by a Michigan State All University Research Initiative Grant.     

Computers in the Exam Room: Differences in Physician–Patient Interaction May Be Due to Physician Experience

Background The use of electronic medical records can improve the technical quality of care, but requires a computer in the exam room. This could adversely affect interpersonal aspects of care, particularly when physicians are inexperienced users of exam room computers. Objective To determine whether physician experience modifies the impact of exam room computers on the physician–patient interaction. Design Cross-sectional surveys of patients and physicians. Setting and Participants One hundred fifty five adults seen for scheduled visits by 11 faculty internists and 12 internal medicine residents in a VA primary care clinic. Measurements Physician and patient assessment of the effect of the computer on the clinical encounter. Main Results Patients seeing residents, compared to those seeing faculty, were more likely to agree that the computer adversely affected the amount of time the physician spent talking to (34% vs 15%, P = 0.01), looking at (45% vs 24%, P = 0.02), and examining them (32% vs 13%, P = 0.009). Moreover, they were more likely to agree that the computer made the visit feel less personal (20% vs 5%, P = 0.017). Few patients thought the computer interfered with their relationship with their physicians (8% vs 8%). Residents were more likely than faculty to report these same adverse effects, but these differences were smaller and not statistically significant. Conclusion Patients seen by residents more often agreed that exam room computers decreased the amount of interpersonal contact. More research is needed to elucidate key tasks and behaviors that facilitate doctor–patient communication in such a setting.     

Contributions of general internal medicine teaching units

OBJECTIVE: To identify and describe general internal medicine teaching units and their educational activities. DESIGN: A cross-sectional mailed survey of heads of general internal medicine teaching units affiliated with U.S. internal medicine training programs who responded between December 1996 and December 1997. MEASUREMENTS AND MAIN RESULTS: Responses were received from 249 (61%) of 409 eligible programs. Responding and nonresponding programs were similar in terms of university affiliation, geographic region, and size of residency program. Fifty percent of faculty received no funding from teaching units, 37% received full-time (50% or more time), and 13% received part-time (under 50% time) funding from units. Only 23% of faculty were primarily located at universities or medical schools. The majority of faculty were classified as clinicians (15% or less time spent in teaching) or clinician-educators (more than 15% time spent in teaching), and few were clinician-researchers (30% or more time spent in research). Thirty-six percent of faculty were internal medicine subspecialists. All units were involved in training internal medicine residents and medical students, and 21% trained fellows of various types. Half of the units had teaching clinics located in underserved areas, and one fourth had teaching clinics serving more than 50% managed care patients. Heads of teaching units reported that 54% of recent graduating residents chose careers in general internal medicine. CONCLUSIONS: General internal medicine teaching units surveyed contributed substantial faculty effort, much of it unfunded and located off-campus, to training medical students, residents, and fellows. A majority of their graduating residents chose generalist careers. Presented at the national meeting of the Society of General Internal Medicine, April 1998, and the Bureau of Health Professions, June 1998. This work was supported by the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Md, grant 103HR960470P000-000; and the Society of General Internal Medicine.     

Effect of Training on Primary Care Residents’ Performance in Brief Alcohol Intervention: A Randomized Controlled Trial

Background Brief alcohol interventions (BAI) reduce alcohol use and related problems in primary care patients with hazardous drinking behavior. The effectiveness of teaching BAI on the performance of primary care residents has not been fully evaluated. Methods A cluster randomized controlled trial was conducted with 26 primary care residents who were randomized to either an 8-hour, interactive BAI training workshop (intervention) or a lipid management workshop (control). During the 6-month period after training (i.e., from October 1, 2003 to March 30, 2004), 506 hazardous drinkers were identified in primary care, 260 of whom were included in the study. Patients were interviewed immediately and then 3 months after meeting with each resident to evaluate their perceptions of the BAI experience and to document drinking patterns. Results Patients reported that BAI trained residents: conducted more components of BAI than did controls (2.4 vs 1.5, p = .001); were more likely to explain safe drinking limits (27% vs 10%, p = .001) and provide feedback on patients’ alcohol use (33% vs 21%, p = .03); and more often sought patient opinions on drinking limits (19% vs 6%, p = .02). No between-group differences were observed in patient drinking patterns or in use of 9 of the 12 BAI components. Conclusions The BAI-trained residents did not put a majority of BAI components into practice, thus it is difficult to evaluate the influence of BAI on the reduction of alcohol use among hazardous drinkers. Dr. Chossis died May 10, 2007. A poster on this study was presented at the 2006 RSA Annual Scientific Meeting held in Baltimore, Maryland, June 26, 2006.     

Family Medicine and Primary Care Internal Medicine Residents' Attitudes Toward Care of the Elderly

Family medicine and primary care internal medicine residents in a university training program were surveyed about their attitudes toward caring for the elderly. Respondents reported satisfaction with care of the elderly. They considered caring for elderly patients to be medically challenging and reported that they learned an appreciable amount of medicine from elderly patients. The residents were less positive about their impact on elderly patients' health and the quality of care they delivered. Rather than supporting the belief that residents have negative attitudes toward the elderly, the study suggests this group of residents has positive attitudes about caring for this population. Their more negative responses about caring for this population. Their more negative responses about the quality of care they deliver suggest they would be receptive to learning more about delivery of health care to the elderly.     

Changing Medical Students' Attitudes Toward Older Adults

Given the growth in the number of older adults and the ageist attitudes many in the health care profession hold, interventions aimed at improving health professionals' attitudes toward older adults are imperative. Vital Visionaries is an intergenerational art program designed to improve medical students' attitudes toward older adults. Participants met for four 2-hour sessions at local art museums to create and discuss art. Three hundred and twenty-eight individuals (112 treatment group, 96 comparison, 120 older adults) in eight cities participated in the program and evaluation. Participants completed pre-and postsurveys that captured their attitude toward older adults, perception of commonality with older adults, and career plans. Findings suggest that medical students' attitudes toward old adults were positive at pretest. However, Vital Visionary students became more positive in their attitudes toward older adults at posttest (p < .001), with a moderate effect size, G = .60, and they felt they had more in common with older adults at posttest (p < .001), with a moderate effect size, G = .64. The program did not influence their career plans (p = .35). Findings from this demonstration project suggest that socializing medical students with healthy older adults through art programs can foster positive attitudes and enhance their sense of commonality with older adults.     

A national survey on the current status of general internal medicine residency education in geriatric medicine

OBJECTIVES: The dramatic increase in the U.S. elderly population expected over the coming decades will place a heavy strain on the current health care system. General internal medicine (GIM) residents need to be prepared to take care of this population. In this study, we document the current and future trends in geriatric education in GIM residency programs. DESIGN, SETTING, PARTICIPANTS: An original survey was mailed to all the GIM residency directors in the United States (N = 390). RESULTS: A 53% response rate was achieved (n = 206). Ninety-three percent of GIM residencies had a required geriatrics curriculum. Seventy one percent of the programs required 13 to 36 half days of geriatric medicine clinical training during the 3-year residency, and 29% required 12 half days or less of clinical training. Nursing homes, outpatient geriatric assessment centers, and nongeriatric ambulatory settings were the predominant training sites for geriatrics in GIM. Training was most often offered in a block format. The average number of physician faculty available to teach geriatrics was 6.4 per program (2.8 full-time equivalents). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education. CONCLUSIONS: A required geriatric medicine curriculum is now included in most GIM residency programs. Variability in the amount of time devoted to geriatrics exists across GIM residencies. Residents in some programs spend very little time in specific, required geriatric medicine clinical experiences. The results of this survey can guide the development of future curricular content and structure. Emphasizing geriatrics in GIM residencies helps ensure that these residents are equipped to care for the expanding aging population.     

Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols

Objective: To improve compliance with computer-generated reminders to perform fecal occult blood testing (FOBT), mammography, and cervical Papanicolaou (Pap) testing. Design: Six-month prospective, randomized, controlled trial. Setting: Academic primary care general internal medicine practice. Subjects: Thirty-one general internal medicine faculty, 145 residents, and 5,407 patients with scheduled visits who were eligible for any of the three cancer screening protocols. Intervention: Primary care teams of internal medicine residents and faculty received either routine computer reminders (control) or the same reminders to which they were required to circle one of four responses: 1) “done/order today,” 2) “not applicable to this patient,” 3) “patient refused,” or 4) “next visit.” Results: Intervention physicians complied more frequently than control physicians with all reminders combined (46% vs 38%, respectively, p=0.002) and separately with reminders for FOBT (61% vs 49%, p=0.0007) and mammography (54% vs 47%, p=0.036) but not cervical Pap testing (21% vs 18%, p=0.2). Intervention residents responded significantly more often than control residents to all reminders together and separately to reminders for FOBT and mammography but not Pap testing. There was no significant difference between intervention and control faculty, but the compliance rate for control faculty was significantly higher than the rate for control residents for all reminders together and separately for FOBT but not mammography or Pap testing. The intervention’s effect was greatest for patients ≥70 years old, with significant results for all tests, together and singly, for residents but not faculty. Intervention physicians felt that the reminders were not applicable 21% of the time (due to inadequate data in patients’ electronic medical records) and stated that their patients refused 10% of the time. Conclusions: Requiring physicians to respond to computer-generated reminders improved their compliance with preventive care protocols, especially for elderly patients for whom control physicians’ compliance was the lowest. However, 100% compliance with cancer screening reminders will be unattainable due to incomplete data and patient refusal. Received from the Regenstrief Institute for Health Care, the Department of Medicine of the Indiana University School of Medicine, and the Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana. Presented at the annual meeting of the Society of General Internal Medicine, May 2–5, 1990, Arlington Virginia. Supported by grant number D28-PE55990 from the Health Research Service Administration and grants number HS-04996 and HS-05626 from the Agency for Health Care Policy and Research.     

Discrimination and abuse in internal medicine residency

OBJECTIVE: To survey the extent to which internal medicine housestaff experience abuse and discrimination in their training. DESIGN: Through a literature review and resident focus groups, we developed a self-administered questionnaire. In this cross-sectional survey, respondents were asked to record the frequency with which they experienced and witnessed different types of abuse and discrimination during residency training, using a 7-point Likert scale. PARTICIPANTS: Internal medicine housestaff in Canada. MEASUREMENTS AND MAIN RESULTS: Of 543 residents in 13 programs participating (84% response rate), 35% were female. Psychological abuse, as reported by attending physicians (68%), patients (79%), and nurses or other health workers (77%), was widespread. Female residents experienced gender discrimination by attending physicians (70%), patients (88%), and nurses (71%); rates for males were 23%, 38%, and 35%, respectively. Females reported being sexually harassed more often than males, by attending physicians (35% vs 4%,p<.01), peers (30% vs 6%,p<.01), and patients (56% vs 18%,p<.01). Physical assault by patients was experienced by 40% of residents. Half of the residents surveyed reported racial discrimination and homophobic remarks in the workplace, perpetrated by all groups of health professionals. CONCLUSIONS: Psychological abuse, gender discrimination, sexual harassment, physical abuse, homophobia, and racial discrimination are prevalent problems during residency training. Housestaff, medical educators, allied health workers, and the public need to work together to address these problems in the training environment. Dr. Cook is a Career Scientist with the Ontario Ministry of Health. For a complete listing, see Appendix A. This study was supported by the Royal College of Physicians and Surgeons of Canada.     

Improving primary care residents’ proficiency in the diagnosis of skin cancer

OBJECTIVE: To determine whether a brief, multicomponent intervention could improve the skin cancer diagnosis and evaluation planning performance of primary care residents to a level equivalent to that of dermatologists. PARTICIPANTS: Fifty-two primary care residents (26 in the control group and 26 in the intervention group) and 13 dermatologists completed a pretest and posttest. DESIGN: A randomized, controlled trial with pretest and posttest measurements of residents’ ability to diagnose and make evaluation plans for lesions indicative of skin cancer. INTERVENTION: The intervention included face-to-face feedback sessions focusing on residents’s performance deficiencies; an interactive seminar including slide presentations, case examples, and live demonstrations; and the Melanoma Prevention Kit including a booklet, magnifying tool, measuring tool, and skin color guide. MEASUREMENTS AND MAIN RESULTS: We compared the abilities of a control and an intervention group of primary care residents, and a group of dermatologists to diagnose and make evaluation plans for six categories of skin lesions including three types of skin cancer—malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. At posttest, both the intervention and control group demonstrated improved performance, with the intervention group revealing significantly larger gains. The intervention group showed greater improvement than the control group across all six diagnostic categories (a gain of 13 percentage points vs 5, p<.05), and in evaluation planning for malignant melanoma (a gain of 46 percentage points vs 36, p<.05) and squamous cell carcinoma (a gain of 42 percentage points vs 21, p<.01). The intervention group performed as well as the dermatologists on five of the six skin cancer diagnosis and evaluation planning scores with the exception of the diagnosis of basal cell carcinoma. CONCLUSIONS: Primary care residents can diagnose and make evaluation plans for cancerous skin lesions, including malignant melanoma, at a level equivalent to that of dermatologists if they receive relevant, targeted education. Supported by the National Cancer Institute, grant 5 R01 CA62959-02.     

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.     

Use of Multidisciplinary Rounds to Simultaneously Improve Quality Outcomes,Enhance Resident Education,and Shorten Length of Stay

BACKGROUND Hospital-based clinicians and educators face a difficult challenge trying to simultaneously improve measurable quality, educate residents in line with ACGME core competencies, while also attending to fiscal concerns such as hospital length of stay (LOS). OBJECTIVE The purpose of this study was to determine the effect of multidisciplinary rounds (MDR) on quality core measure performance, resident education, and hospital length of stay. DESIGN Pre and post observational study assessing the impact of MDR during its first year of implementation. SETTING The Norwalk Hospital is a 328-bed, university-affiliated community teaching hospital in an urban setting with a total of 44 Internal Medicine residents. METHODS Joint Commission on Accreditation of Healthcare Organizations (JCAHO) core measure performance was obtained on a monthly basis for selected heart failure (CHF), pneumonia, and acute myocardial infarction (AMI) measures addressed on the general medical service. Resident knowledge and attitudes about MDR were determined by an anonymous questionnaire. LOS and monthly core measure performance rates were adjusted for patient characteristics and secular trends using linear spline logistic regression modeling. RESULTS Institution of MDR was associated with a significant improvement in quality core measure performance in targeted areas of CHF from 65% to 76% (p < .001), AMI from 89% to 96% (p = .004), pneumonia from 27% to 70% (p < .001), and all combined from 59% to 78% (p < .001). Adjusted overall monthly performance rates also improved during MDR (odds ratio [OR] 1.09, CI 1.06–1.12, p < .001). Residents reported substantial improvements in core measure knowledge, systems-based care, and communication after institution of MDR (p < .001). Residents also agreed that MDR improved efficiency, delivery of evidence-based care, and relationships with involved disciplines. Adjusted average LOS decreased 0.5 (95% CI 0.1–0.8) days for patients with a target core measure diagnosis of either CHF, pneumonia, or AMI (p < .01 ) and by 0.6 (95% CI 0.5–0.7) days for all medicine DRGs (p < .001). CONCLUSIONS Resident-centered MDR is an effective process using no additional resources that simultaneously improves quality of care while enhancing resident education and is associated with shortened length of stay. This study was presented in part in workshop and oral format at the 27th Society of General Internal Medicine Annual Meeting, May 12–15, 2004, Chicago, IL