Transforming Primary Care Training—Patient-Centered Medical Home Entrustable Professional Activities for Internal Medicine Residents

INTRODUCTION

The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice.

AIM

We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs?

PROGRAM DESCRIPTION

The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, ‘medical home builder’ tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs).

RESULTS

The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs.

DISCUSSION

The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.     

Complexity in Graduate Medical Education: A Collaborative Education Agenda for Internal Medicine and Geriatric Medicine

Internal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.     

Rating the Quality of Entrustable Professional Activities: Content Validation and Associations with the Clinical Context

BACKGROUND

Entrustable professional activities (EPAs) have been developed to assess resident physicians with respect to Accreditation Council for Graduate Medical Education (ACGME) competencies and milestones. Although the feasibility of using EPAs has been reported, we are unaware of previous validation studies on EPAs and potential associations between EPA quality scores and characteristics of educational programs.

OBJECTIVES

Our aim was to validate an instrument for assessing the quality of EPAs for assessment of internal medicine residents, and to examine associations between EPA quality scores and features of rotations.

DESIGN

This was a prospective content validation study to design an instrument to measure the quality of EPAs that were written for assessing internal medicine residents.

PARTICIPANTS

Residency leadership at Mayo Clinic, Rochester participated in this study. This included the Program Director, Associate program directors and individual rotation directors.

INTERVENTIONS

The authors reviewed salient literature. Items were developed to reflect domains of EPAs useful for assessment. The instrument underwent further testing and refinement. Each participating rotation director created EPAs that they felt would be meaningful to assess learner performance in their area. These 229 EPAs were then assessed with the QUEPA instrument to rate the quality of each EPA.

MAIN MEASURES

Performance characteristics of the QUEPA are reported. Quality ratings of EPAs were compared to the primary ACGME competency, inpatient versus outpatient setting and specialty type.

KEY RESULTS

QUEPA tool scores demonstrated excellent reliability (ICC range 0.72 to 0.94). Higher ratings were given to inpatient versus outpatient (3.88, 3.66; p?=?0.03) focused EPAs. Medical knowledge EPAs scored significantly lower than EPAs assessing other competencies (3.34, 4.00; p?<?0.0001).

CONCLUSIONS

The QUEPA tool is supported by good validity evidence and may help in rating the quality of EPAs developed by individual programs. Programs should take care when writing EPAs for the outpatient setting or to assess medical knowledge, as these tended to be rated lower.

     

The problem resident behavior guide: strategies for remediation

In 2012, the ACGME supplemented the core competencies with outcomes-based milestones for resident performance within the six competency domains. These milestones address the knowledge, skills, abilities, attitudes, and experiences that a resident is expected to progress through during the course of training. Even prior to the initiation of the milestones, there was a paucity of EM literature addressing the remediation of problem resident behaviors and there remain few readily accessible tools to aid in the implementation of a remediation plan. The goal of the “Problem Resident Behavior Guide” is to provide specific strategies for resident remediation based on deficiencies identified within the framework of the EM milestones. The “Problem Resident Behavior Guide” is a written instructional manual that provides concrete examples of remediation strategies to address specific milestone deficiencies. The more than 200 strategies stem from the experiences of the authors who have professional experience at three different academic hospitals and emergency medicine residency programs, supplemented by recommendations from educational leaders as well as utilization of valuable education adjuncts, such as focused simulation exercises, lecture preparation, and themed ED shifts. Most recommendations require active participation by the resident with guidance by faculty to achieve the remediation expectations. The ACGME outcomes-based milestones aid in the identification of deficiencies with regards to resident performance without providing recommendations on remediation. The Problem Resident Behavior Guide can therefore have a significant impact by filling in this gap.     

What Is a Geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs End‐of‐Training Entrustable Professional Activities for Geriatric Medicine

Entrustable professional activities (EPAs) describe the core work that constitutes a discipline's specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end‐of‐training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatrician's fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.     

Telehealth Competencies in Medical Education: New Frontiers in Faculty Development and Learner Assessments

Telehealth visits have become an integral model of healthcare delivery since the COVID-19 pandemic. This rapid expansion of telehealthcare delivery has forced faculty development and trainee education in telehealth to occur simultaneously. In response, academic medical institutions have quickly implemented clinical training to teach digital health skills to providers across the medical education continuum. Yet, learners of all levels must still receive continual assessment and feedback on their skills to align with the telehealth competencies and milestones set forth by the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME). This paper discusses key educational needs and emerging areas for faculty development in telehealth teaching and assessment of telehealth competencies. It proposes strategies for the successful integration of the AAMC telehealth competencies and ACGME milestones into medical education, including skills in communication, data gathering, and patient safety with appropriate telehealth use. Direct observation tools in the paper offer educators novel instruments to assess telehealth competencies in medical students, residents, and peer faculty. The integration of AAMC and ACGME telehealth competencies and the new assessment tools in this paper provide a unique perspective to advance clinical practice and teaching skills in telehealthcare delivery.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07564-8.KEY WORDS: telehealth, telemedicine, virtual visits, medical education, competencies, milestones, electronic health records     

The use of clinical decision-support tools to facilitate geriatric education

Innovative methods are needed to incorporate effective geriatric education into internal medicine residency programs. The purpose of this report is to describe the development and use of clinical decision-support (CDS) tools to facilitate geriatric education and improve the care delivered to older adults in an academic internal medicine residency ambulatory care clinic. Starting in 2009, CDS tools were implemented as a major strategy of an initiative to improve resident physician clinical competencies in geriatrics and improve the quality of care and quality of life of older adults. These tools, designed to improve resident assessment and action for each of three educational modules (falls, vision, and dementia) were embedded within the ambulatory electronic medical record (EMR) and provided a method of point-of-care training to residents caring for older adults. One hundred internal medicine residents supervised by 17 general internal medicine faculty members participated. Data regarding CDS use and associated outcomes were recorded and extracted from the ambulatory clinic EMR. Residents screened between 67% and 88% of eligible patients using CDS algorithms; rates of additional assessment and referral or further examination reflected the prevalence of the condition in the patient population. Although further development may be necessary, CDS tools are a promising modality to supplement geriatric postgraduate education while simultaneously improving patient care.     

Integration of cytogenetic data with genome maps and available probes: present status and future promise

The National Cancer Institute has established an initiative, called the Cancer Chromosome Aberration Project (Ccap), in order to link and integrate the physical and genetic maps of the human genome with cytogenetic data and the location of chromosomal rearrangements in human diseases. This goal will be achieved by high-resolution fluorescence in situ hybridization (FISH) mapping of colony-purified bacterial artificial chromosome (BAC) clones spaced at 1-to 2-Mb intervals across the entire genome. All BAC clones will be anchored on the physical map by the presence of a mapped sequence tagged site (STS). The generation of a publicly accessible clone repository will allow convenient distribution of these BACs. Ccap data can be correlated with other cancer-associated and genomic databases, such as the catalog of chromosomal aberrations in cancer and the emerging full genomic sequence. We anticipate that the use of Ccap clones will expedite and refine the mapping of chromosomal breakpoints. The eventual set of approximately 3,000 Ccap BACs should facilitate the production of BAC-containing DNA chips for assessing copy number of genomic segments by matrix comparative genomic hybridization. In addition, the repository will provide genome-wide tools for defining chromosomal aberrations in cytological specimens by interphase cytogenetics. The Ccap Web site illustrates goals and progress of this initiative (http://www.ncbi.nlm.nih.gov/CCAP/).     

Subtle skills: Using objective structured clinical examinations to assess gastroenterology fellow performance in system based practice milestones

BACKGROUND System based practice(SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless,structured assessment is required for training programs. We hypothesized that objective structured clinical examination(OSCE) would be an effective tool for assessment of SBP.AIM To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE.METHODS For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twentysix first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey.RESULTS Survey response rate was 100%. The average composite score across SBP milestones for all cases were 6.22(SBP1), 4.34(SBP2), 3.35(SBP3), and 6.42(SBP4)out of 9. The lowest composite score was in SBP 3, which asks fellows to advocate for cost effective care. This highest score was in patient care 2, which asks fellows to develop comprehensive management plans. Discrepancies were identified between the fellows' perceived performance in their self-assessments and Standardized Patient checklist evaluations for each case. Eighty-seven percent of fellows agreed that OSCEs are an important component of their clinical training,and 83% stated that the cases were similar to actual clinical encounters. All participating fellows stated that the immediate feedback was "very useful." One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice.CONCLUSION OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.     

Probe mapping to facilitate transposon-based DNA sequencing.

A promising strategy for DNA sequencing exploits transposons to provide mobile sites for the binding of sequencing primers. For such a strategy to be maximally efficient, the location and orientation of the transposon must be readily determined and the insertion sites should be randomly distributed. We demonstrate an efficient probe-based method for the localization and orientation of transposon-borne primer sites, which is adaptable to large-scale sequencing strategies. This approach requires no prior restriction enzyme mapping or knowledge of the cloned sequence and eliminates the inefficiency inherent in totally random sequencing methods. To test the efficiency of probe mapping, 49 insertions of the transposon gamma delta (Tn1000) in a cloned fragment of Drosophila melanogaster DNA were mapped and oriented. In addition, oligonucleotide primers specific for unique subterminal gamma delta segments were used to prime dideoxynucleotide double-stranded sequencing. These data provided an opportunity to rigorously examine gamma delta insertion sites. The insertions were quite randomly distributed, even though the target DNA fragment had both A + T-rich and G + C-rich regions; in G + C-rich DNA, the insertions were found in A + T-rich "valleys." These data demonstrate that gamma delta is an excellent choice for supplying mobile primer binding sites to cloned DNA and that transposon-based probe mapping permits the sequences of large cloned segments to be determined without any subcloning.     

Psychiatric Illness,Substance Use,and Viral Suppression Among HIV-Positive Men of Color Who Have Sex with Men in Los Angeles

For individuals living with human immunodeficiency virus (HIV), viral suppression positively affects quality and length of life and reduces risks for HIV transmission. Men of color who have sex with men (MoCSM) who have been diagnosed with HIV have disproportionately low rates of viral suppression, with concomitant increases in incidence. We identified specific social, structural, and psychiatric factors associated with viral suppression among a sample of 155 HIV-positive MoCSM. Cigarette smoking and biological markers of recent drug use were significantly associated with detectable viral load. In contrast, individuals reporting a history of psychiatric illness during medical examination were more likely to be virally suppressed. Further analyses demonstrated that psychiatric illness may affect virologic outcomes through increased probability of being prescribed HIV medications. Alternatively, cigarette smoking and drug use appear to negatively affect subsequent HIV Care Continuum milestones such as medication adherence. Findings provide support for comprehensive intervention programs that emphasize prevention and treatment of cigarette, methamphetamine, and other drug use, and promote improved connection to psychiatric care. Continual achievement of this goal may be a crucial step to increase rates of viral suppression and slow HIV incidence in communities of MoCSM in Los Angeles and other urban areas.     

Using Life History Narratives to Educate Staff Members About Personhood in Assisted Living

Oral life history narratives are a promising method to promote person-centered values of personhood and belonging. This project used resident oral history interviews to educate staff members in an assisted-living setting about personhood. A single group pre-post test design evaluated impacts on 37 staff members to assess their use of resident videotaped oral history interviews and impacts on their perceived knowledge of residents. Perceived knowledge of residents declined (p = .003) between pretest and posttest. Older staff members were less likely to view a video. Staff members are interested in resident oral history biographies and identify them as helpful for delivering care. Oral history methods might provide an opportunity for staff members to promote personhood by allowing them to expand their understanding of resident preferences, values, and experiences.     

Noninvasive measurement of anatomic structure and intraluminal oxygenation in the gastrointestinal tract of living mice with spatial and spectral EPR imaging

EPR imaging has emerged as an important tool for noninvasive three-dimensional (3D) spatial mapping of free radicals in biological tissues. Spectral-spatial EPR imaging enables mapping of the spectral information at each spatial position, and, from the observed line width, the localized tissue oxygenation can be mapped. We report the development of EPR imaging instrumentation enabling 3D spatial and spectral-spatial EPR imaging of small animals. This instrumentation, along with the use of a biocompatible charcoal oximetry-probe suspension, enabled 3D spatial imaging of the gastrointestinal (GI) tract, along with mapping of oxygenation in living mice. By using these techniques, the oxygen tension was mapped at different levels of the GI tract from the stomach to the rectum. The results clearly show the presence of a marked oxygen gradient from the proximal to the distal GI tract, which decreases after respiratory arrest. This technique for in vivo mapping of oxygenation is a promising method, enabling the noninvasive imaging of oxygen within the normal GI tract. This method should be useful in determining the alterations in oxygenation associated with disease.     

A framework for measuring timeliness in the outbreak response path: lessons learned from the Middle East respiratory syndrome (MERS) epidemic,September 2012 to January 2019

BackgroundEpidemics are a constant threat in the 21st century, particularly disease outbreaks following spillover of an animal virus to humans. Timeliness, a key metric in epidemic response, can be examined to identify critical steps and delays in public health action.AimTo examine timeliness, we analysed the response to the Middle East respiratory syndrome (MERS) epidemic, with a focus on the international and One Health response efforts.MethodsWe performed a historical review of the MERS epidemic between September 2012 and January 2019 in three steps: (i) the construction of a timeline identifying critical events in the global response, (ii) the performance of a critical path analysis to define outbreak milestones and (iii) a time gap analysis to measure timeliness in the execution of these milestones.ResultsWe proposed 14 MERS-specific milestones at different phases of the epidemic, assessing timeliness of the public health response as well as at the animal–human interface, where we identified the most significant delays.ConclusionsWhen comparing timeliness across three coronavirus epidemics, i.e. MERS (2012), SARS (2002) and COVID-19 (2019), we identified clear improvements over time for certain milestones including laboratory confirmation and diagnostics development, while this was not as apparent for others, as the identification of zoonotic hosts. To more efficiently respond to emerging threats, the global health community should widely assess and tackle specific delays in implementing response interventions by addressing challenges in the sharing of information, data and resources, as well as efficiency, quality, transparency and reliability of reporting events.     

Utilization of a training portfolio in thoracic and cardiovascular surgery: the example of the French platform-EPIFORM

Thoracic and cardiovascular surgery requires learning both theoretical knowledge and technical skills. In this surgical field, several disparities exist between the different training programs around the world. This report describes the implementation of a portfolio in the teaching and assessment of French trainees in Thoracic and Cardiovascular surgery, following an electronic logbook model, aiming to improve the training program. The French surgical course is a twelve semesters’ curriculum divided in 3 parts, each part containing knowledge, technical skills and behaviors objectives to be validated, defined by the French College of Thoracic and Cardiovascular surgery. The competencies are marked in the logbook, following a declarative model where the surgical trainee fills every surgical procedure attended (all or part) if he/she has observed, partially or fully performed, or supervised another trainee. All the surgical procedures are linked to theoretical e-learning lessons and each e-learning lesson includes a self-evaluation. This constitutes a competency-based assessment model with milestones both for surgeon trainees and their mentors. This portfolio also contains complementary tools such as an automated publication point calculation, a formatted curriculum vitae generator, and several contact tools between trainees. Implementation of a dedicated portfolio following an electronic logbook model appears to be a relevant pedagogic tool and survey element in the thoracic and cardiovascular surgery training program. Its use may lead to potential educational benefits for the trainee, reliable competency assessment for the supervising surgeon and for scientific society or national college.     

A Comprehensive Needs Assessment Tool for Planning RHD Control Programs in Limited Resource Settings

Rheumatic heart disease (RHD) is an important cause of disability and death in low- and middle-income countries. However, evidence-based interventions have not been implemented systematically in many countries. We present a RHD Needs Assessment Tool (NAT) that can be used at country or regional levels to systematically develop and plan comprehensive RHD control programs and to provide baseline data for program monitoring and evaluation. The RHD NAT follows a mixed-methods approach using quantitative and qualitative data collection instruments. Evidence is mapped to a conceptual model that follows a patient through the natural history of RHD. The NAT has 4 phases: 1) situational assessment; 2) facility-based assessment of epidemiology and health system capacity; 3) patient and provider experience of RHD using ethnographic methods; and 4) intervention planning, including stakeholder mapping and development of a monitoring and evaluation framework. The RHD NAT is designed to paint a comprehensive picture of RHD care in an endemic setting and to identify the major gaps to disseminating and implementing evidence-based interventions.     

Future development of nursing home quality indicators

Nursing home quality indicators have been developed over the past 10 years to quantify nursing home quality and to draw systematic comparisons between facilities. Although these indicators have been applied widely for nursing home regulation, quality improvement, and public reporting, researchers and stakeholders have raised concerns about their accuracy and usefulness. We critically evaluate nursing home quality indicators from the standpoint of theory, measurement, and application, and we recommend strategies to make the indicators more valuable as quality assessment tools. We recommend that (a) more comprehensive quality indicators should be developed in conjunction with the new Minimum Data Set 3.0; (b) the validity and reliability of the indicators should be evaluated thoroughly with respect to both measurement and application; (c) statistical criteria should be incorporated explicitly into quality indicator scoring and outlier targeting; (d) the dimensionality and theoretical structure of the quality indicators should be carefully examined; (e) risk adjustment methods should be refined and broadened; and (f) quality indicator reporting systems should be strengthened and tailored to stakeholders' needs.     

How diabetes risk assessment tools are implemented in practice: A systematic review

This review aimed to explore the extent of the use of diabetes risk assessment tools and to determine influential variables associated with the implementation of these tools. CINAHL, Google Scholar, ISI Citation Indexes, PubMed, and Scopus were searched from inception to January 2013. Studies that reported the use of diabetes risk assessment tools to identify individuals at risk of diabetes were included. Of the 1719 articles identified, 24 were included. Follow-up of high risk individuals for diagnosis of diabetes was conducted in 5 studies. Barriers to the uptake of diabetes risk assessment tools by healthcare practitioners included (1) attitudes toward the tools; (2) impracticality of using the tools and (3) lack of reimbursement and regulatory support. Individuals were reluctant to undertake self-assessment of diabetes risk due to (1) lack of perceived severity of type 2 diabetes; (2) impracticality of the tools; and (3) concerns related to finding out the results. The current use of non-invasive diabetes risk assessment scores as screening tools appears to be limited. Practical follow up systems as well as strategies to address other barriers to the implementation of diabetes risk assessment tools are essential and need to be developed.     

Measuring outcomes of a one-minute preceptor faculty development workshop

BACKGROUND: Measuring outcomes of faculty development programs is difficult and infrequently attempted beyond measuring participant satisfaction with the program. Few studies have validated evaluation tools to assess the effectiveness of faculty development programs, and learners have rarely participated in assessing improvement of faculty who participate in such programs. OBJECTIVE: To develop a questionnaire to measure the effectiveness of an enhanced 1-minute preceptor (OMP) faculty development workshop via faculty self-assessment and resident assessment of faculty, and to use the questionnaire to assess an OMP faculty development workshop. DESIGN AND MEASUREMENTS: We developed and tested a questionnaire to assess the 5 "microskills" of a OMP faculty development program, and performed faculty self-assessment and resident assessment using the questionnaire 6 to 18 months before and 6 to 18 months after our experiential skills improvement workshop. PARTICIPANTS: Sixty-eight internal medicine continuity clinic preceptors (44 control and 24 intervention faculty) at a university, a veteran's affairs hospital, and 2 community internal medicine training sites. RESULTS: Twenty-two participants (92%) completed pre- and postintervention questionnaires. Residents completed 94 preintervention questionnaires and 58 postintervention questionnaires on participant faculty. Faculty reported improvement in behavior following the intervention. Residents reported no significant improvements in faculty teaching behaviors following the intervention. CONCLUSION: We attempted to rigorously evaluate a faculty development program based on the OMP. Although the intervention did not show statistically significant changes in teaching behavior, we believe that this study is an important step in extending assessment of faculty development to include resident evaluation of participating faculty.