Preparedness for clinical practice: reports of graduating residents at academic health centers

Mortality and Severe Complications Among Newly Graduated Surgeons in the United States

OBJECTIVE

To evaluate severe complications and mortality over years of independent practice among general surgeons.

BACKGROUND

Despite concerns that newly graduated general surgeons may be unprepared for independent practice, it is unclear whether patient outcomes differ between early and later career surgeons.

METHODS

We used Medicare claims for patients discharged between July 1, 2007 and December 31, 2019 to evaluate 30-day severe complications and mortality for 26 operations defined as core procedures by the American Board of Surgery. Generalized additive mixed models were used to assess the association between surgeon years in practice and 30-day outcomes while adjusting for differences in patient, hospital, and surgeon characteristics.

RESULTS

The cohort included 1,329,358 operations performed by 14,399 surgeons. In generalized mixed models, the relative risk (RR) of mortality was higher among surgeons in their first year of practice compared with surgeons in their 15th year of practice [5.5% (95% CI: 4.1%-7.3%) vs 4.7% (95% CI: 3.5%-6.3%), RR: 1.17 (95% CI: 1.11-1.22)]. Similarly, the RR of severe complications was higher among surgeons in their first year of practice compared with surgeons in their 15th year of practice [7.5% (95% CI: 6.6%-8.5%) versus 6.9% (95% CI: 6.1%-7.9%), RR: 1.08 (95% CI: 1.03-1.14)]. When stratified by individual operation, 21 operations had a significantly higher RR of mortality and all 26 operations had a significantly higher RR of severe complications in the first compared with the 15th year of practice.

CONCLUSIONS

Among general surgeons performing common operations, rates of mortality and severe complications were higher among newly graduated surgeons compared with later career surgeons.

Development of low back pain curriculum content standards for entry-level clinical training

BACKGROUND

The management of low back pain (LBP) is highly variable and patients often receive management that is not recommended and/or miss out on recommended care. Clinician knowledge and behaviours are strongly influenced by entry-level clinical training and are commonly cited as barriers to implementing evidence-based management. Currently there are no internationally recognised curriculum standards for the teaching of LBP content to ensure graduating clinicians have the appropriate knowledge and competencies to assess and manage LBP. We formed an international interdisciplinary working group to develop curriculum content standards for the teaching of LBP in entry-level clinical training programs.

METHODS

The working group included representatives from 11 countries: 18 academics and clinicians from healthcare professions who deal with the management of LBP (medicine, physiotherapy, chiropractic, osteopathy, pharmacology, and psychology), seven professional organisation representatives (medicine, physiotherapy, chiropractic, spine societies), and one healthcare consumer. A literature review was performed, including database and hand searches of guidelines and accreditation, curricula, and other policy documents, to identify gaps in current LBP teaching and recommended entry-level knowledge and competencies. The steering group (authors) drafted the initial LBP Curriculum Content Standards (LBP-CCS), which were discussed and modified through two review rounds with the working group.

RESULTS

Sixty-two documents informed the draft standards. The final LBP-CCS consisted of four broad topics covering the epidemiology, biopsychosocial contributors, assessment, and management of LBP. For each topic, key knowledge and competencies to be achieved by the end of entry-level clinical training were described.

CONCLUSION

We have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to inform or benchmark the content of curricula related to LBP in new or existing entry-level clinical training programs.

Are early career family physicians prepared for practice in Canada? A qualitative study

BACKGROUND

In Canada, the College of Family Physicians of Canada (CFPC) introduced Competency Based Medical Education to prepare and train family medicine residents to be competent to enter and adapt to the independent practice of comprehensive family medicine. Despite its implementation, the scope of practice is narrowing. This study aims to understand the degree to which early career Family Physicians (FPs) are prepared for independent practice.

METHOD

A qualitative design was used for this study. A survey and focus groups were conducted with early-career FPs who completed residency training in Canada. The survey and focus groups examined the degree of preparedness of early career FPs in relation to 37 core professional activities identified by the CFPC's Residency Training Profile. Descriptive statistics and qualitative content analysis were conducted.

RESULTS

Seventy-five participants from across Canada participated in the survey, and 59 participated in the focus groups. Early career FPs reported being well prepared to provide continuous and coordinated care for patients with common presentations and deliver various services to different populations. FPs were also well prepared to manage the electronic medical record, participate in team-based care, provide regular and after-hours coverage, and assume leadership and teaching roles. However, FPs reported being less prepared for virtual care, business management, providing culturally safe care, delivering specific services in emergency care hospitals, obstetrics, self-care, engaging with the local communities, and conducting research activities.

CONCLUSIONS

Early career FPs do not feel fully prepared for practice in all 37 core activities in the Residency Training Profile. As part of the introduction of the three-year program by the CFPC, the postgraduate family medicine training should consider providing more exposure to learning opportunities and developing curricula in the areas where FPs are unprepared for practice. These changes could facilitate the production of a FP workforce better prepared to manage the dynamic and complex challenges and dilemmas faced in independent practice.

Implementation of a New Hampshire community-initiated response to the opioid crisis: A mixed-methods process evaluation of Safe Station

BACKGROUND

New Hampshire (NH) ranked first for fentanyl- and all opioid-related overdose deaths per capita from 2014 to 2016 and third in 2017 with no rate reduction from the previous year relative to all other states in the US. In response to the opioid crisis in NH, Manchester Fire Department (MFD), the state's largest city fire department, launched the Safe Station program in 2016 in partnership with other community organizations. This community-based response to the crisis-described as a connection to recovery-focuses on reducing barriers to accessing resources for people with substance use and related problems. The study aim is to characterize the multi-organizational partnerships and workflow of the Safe Station model and identify key components that are engaging, effective, replicable, and sustainable.

METHODS

A mixed-methods design included: semi-structured qualitative interviews conducted with 110 stakeholders from six groups of community partners (Safe Station clients, MFD staff and leadership, and local emergency department, ambulance, and treatment partner staff); implementation and sustainability surveys (completed by MFD stakeholders); and ethnographic observations conducted at MFD. Qualitative data were content analyzed and coded using the Consolidated Framework for Implementation Research. Survey subscales were scored and evaluated to corroborate the qualitative findings.

RESULTS

Community partners identified key program characteristics including firefighter compassion, low-threshold access, and immediacy of service linkage. Implementation and sustainability survey data corroborate the qualitative interview and observation data in these areas. All participants agreed that community partnerships are key to the program's success. There were mixed evaluations of the quality of communication among the organizations.

CONCLUSION

Safe Station is a novel response to the opioid crisis in New Hampshire that offers immediate, non-judgmental access to services for persons with opioid use disorders requiring community-wide engagement and communication. Data convergence provides guidance to the sustainability and replicability of the program.

Defining the Core Skills and Activities of the Attending Physician in Post-Acute and Long-Term Care

The American Board of Post-Acute and Long-Term Care Medicine (ABPLM) contracted with a psychometric firm to perform a 3-phase Job Analysis following best practices. Literature was reviewed, a task force of subject matter experts was convened, a survey was developed and sent via Survey Monkey to attending physicians practicing in post-acute and long-term care settings (PALTC). The task force refined a comprehensive list of the tasks, knowledge, and medical knowledge needed in the role of attending physician in PALTC. These items were written as statements and edited until consensus was reached on their accuracy, conciseness, and lack of overlap. Task statements described distinct, identifiable, and specific practice-related activities relevant across multiple care settings. Knowledge statements described previously acquired information considered necessary to effectively perform such tasks. The survey consisted of 260 items, including 21 demographic questions, 115 task statements, 73 knowledge statements, and 72 medical knowledge statements. The survey was disseminated via e-mail invitations to Society for Post-Acute and Long-Term Care (AMDA) members and through an online link available through ABPLM's website. A total of 389 respondents participated. Survey data were analyzed with statistical analysis software SPSS. For each task and knowledge statement, an Overall Task Rating and Knowledge Rating were developed by combining the importance rating weighted at 65% and (for task) the frequency rating or (for knowledge) the cognitive level weighted at 35%. One task statement and 1 medical knowledge statement had a mean importance rating lower than 2.5 and were dropped from further review, resulting in a final count of 114 task, 73 knowledge, and 71 medical knowledge statements (258 total). The results of this Job Analysis highlight the unique and specific nature of medical care provided by attending physicians across a range of PALTC settings. These findings lay a foundation for Focused Practice Designation or Subspecialty in PALTC and changes in practice and policy.

Medical Staffing Organization and Quality of Care Outcomes in Post-acute Care Settings

BACKGROUND AND OBJECTIVES

Medical providers are significant drivers of care in post-acute long-term care (PALTC) settings, yet little research has examined the medical provider workforce and its role in ensuring quality of care.

RESEARCH DESIGN AND METHODS

This study examined the impact of nursing home medical staffing organization (NHMSO) dimensions on the quality of care in U.S. nursing homes. The principal data source was a survey specifically designed to study medical staff organization for post-acute care. Respondents were medical directors and attending physicians providing PALTC. We linked a number of medical provider and nursing home characteristics to the Centers for Medicaid and Medicare Services Nursing Home Compare quality measures hypothesized to be sensitive to input by medical providers.

RESULTS

From the sample of nursing home medical providers surveyed (n = 1,511), 560 responses were received, yielding a 37% response rate; 425 medical provider responses contained sufficient data for analysis. The results of the impact of NHMSO dimensions were mixed, with many domains not having any significance or having negative relationships between provider characteristics and quality measures. Respondents who reported having a formal process for granting privileges and nursing homes with direct employment of physicians reported significantly fewer emergency visits.

DISCUSSION AND IMPLICATIONS

Further research is needed regarding what quality measures are sensitive to both medical provider characteristics and NHMSO characteristics.

Quality of Outpatient Depression Treatment in Patients With Comorbid Substance Use Disorder

OBJECTIVE

Clinical practice guidelines recommend concurrent treatment of co-occurring depression and substance use disorders; however, the degree to which patients with substance use disorders receive guideline-concordant treatment for depression is unknown. The authors investigated the provision of guideline-concordant depression treatment to patients with and without substance use disorders in a large integrated health care system.

METHODS

In a retrospective cohort study of 53,034 patients diagnosed with a depressive disorder in fiscal year 2017 in the U.S. Veterans Health Administration, the authors assessed the association of comorbid substance use disorders with guideline-concordant depression treatment, including both medication and psychotherapy, while adjusting for patient demographic and clinical characteristics.

RESULTS

Guideline-concordant depression treatment was lower across metrics for patients with co-occurring depression and substance use disorders compared to those without substance use disorders. Consistent findings emerged in covariate-adjusted models of antidepressant treatment, such that patients with substance use disorders had 21% lower odds of guideline-concordant acute treatment (adjusted odds ratio=0.79, 95% CI=0.73, 0.84) and 26% lower odds of continuation of treatment (adjusted odds ratio=0.74, 95% CI=0.69, 0.79). With regard to psychotherapy, patients with co-occurring depression and substance use disorders had 13% lower odds (adjusted odds ratio=0.87, 95% CI=0.82, 0.91) of adequate acute-phase treatment and 19% lower odds (adjusted odds ratio=0.81; 95% CI=0.73, 0.89) of psychotherapy continuation.

CONCLUSIONS

Despite the availability of effective treatments for depression, patients with co-occurring substance use disorders are less likely to receive guideline-concordant depression treatment. Efforts to improve the provision of care to those with co-occurring substance use disorders should focus on clinician-based interventions and use of integrated care models to improve the quality of depression treatment.

Examination of resident characteristics associated with interest in primary care and identification of barriers to cross-cultural care

BACKGROUND

There is an increasing shortage of primary care physicians in the U.S. The difficult task of addressing patients' sociocultural needs is one reason residents do not pursue primary care. However, associations between residents' perceived barriers to cross-cultural care provision and career interest in primary care have not been investigated.

OBJECTIVE

We examined residents' career interest in primary care and associations with resident characteristics and their perceived barriers in providing cross-cultural care.

METHODS

We conducted a cross-sectional analysis of a resident survey from the 2018-2019 academic year. We first described residents' sociodemographic characteristics based on their career interest in primary care (Chi-square test). Our primary outcome was high career interest in primary care. We further examined associations between residents' characteristics and perceived barriers to cross-cultural care.

RESULTS

The study included 155 family medicine, pediatrics, and internal medicine residents (response rate 68.2%), with 17 expressing high career interest in primary care. There were significant differences in high career interest by race/ethnicity, as Non-White race was associated with high career interest in primary care (p < 0.01). Resident characteristics associated with identifying multiple barriers to cross-cultural care included disadvantaged background, multilingualism, and foreign-born parents (all p-values< 0.05). There were no significant associations between high career interest in primary care and barriers to cross-cultural care.

CONCLUSION

Residents from diverse racial/ethnic and socioeconomic backgrounds demonstrated higher career interest in primary care and perceived more barriers to cross-cultural care, underscoring the importance of increasing physician workforce diversity to address the primary care shortage and to improve cross-cultural care.

Building a Shared Mental Model of Competence Across the Continuum: Trainee Perceptions of Subinternships for Residency Preparation

INTRODUCTION

Toward a vision of competency-based medical education (CBME) spanning the undergraduate to graduate medical education (GME) continuum, University of Minnesota Medical School (UMMS) developed the Subinternship in Critical Care (SICC) offered across specialties and sites. Explicit course objectives and assessments focus on internship preparedness, emphasizing direct observation of handovers (Core Entrustable Professional Activity, "EPA," 8) and cross-cover duties (EPA 10).

METHODS

To evaluate students' perceptions of the SICC's and other clerkships' effectiveness toward internship preparedness, all 2016 and 2017 UMMS graduates in GME training (n = 440) were surveyed regarding skill development and assessment among Core EPAs 1, 4, 6, 8, 9, 10. Analysis included descriptive statistics plus chi-squared and Kappa agreement tests.

RESULTS

Respondents (n = 147, response rate 33%) rated the SICC as a rotation during which they gained most competence among EPAs both more (#4, 57% rated important; #8, 75%; #10, 70%) and less explicit (#6, 53%; #9, 69%) per rotation objectives. Assessments of EPA 8 (80% rated important) and 10 (76%) were frequently perceived as important toward residency preparedness. Agreement between importance of EPA development and assessment was moderate (Kappa = 0.40-0.59, all surveyed EPAs).

CONCLUSIONS

Graduates' perceptions support the SICC's educational utility and assessments. Based on this and other insight from the SICC, the authors propose implications toward collectively envisioning the continuum of physician competency.

Establishing an Orthopedic Program-Specific, Comprehensive Competency-Based Education Program

BACKGROUND

Competency-based education (CBE) seeks to determine resident proficiency in the knowledge, skills, and behaviors required for independent patient care. Multiple assessment instruments evaluate technical skills or direct patient care in the clinic setting, but there are few reports incorporating both within an orthopedic specialty rotation. This study reports a residency program's comprehensive CBE initiative using formative assessments in the clinic and operating room during a sports medicine rotation.

MATERIALS AND METHODS

The sports medicine rotation used validated formative assessments to evaluate resident performance during clinic encounters and program-defined surgical entrustable professional activities (EPAs). Junior resident (postgraduate year [PGY] 1-2) EPAs included basic knee/shoulder arthroscopic procedures. Senior resident (PYG 5) EPAs comprised anterior cruciate ligament reconstruction, biceps tenodesis, shoulder stabilization, and rotator cuff repair. Assessment scores were compared between individuals and PGY groups.

RESULTS

Sixty-six clinical skills (CS) and 106 surgical skills assessments were conducted for 22 residents in one academic year. Surgical skills assessments demonstrated significant differences between each PGY group (P < 0.01). All PGY2 and PGY5 residents achieved independence on the evaluated EPAs. PGY5s earned higher scores in CS assessments than the other classes (P < 0.01). PGY2 residents scored higher than PGY1s in 7 of 9 CS domains. CS independence was achieved by 21 of 22 residents by the end of the rotation.

CONCLUSIONS

The CBE program effectively quantified expected differences in resident performance by PGY for clinic and surgical assessments on a sports medicine rotation. Assessments built an environment where feedback was more structured and standardized, creating a culture to improve resident education.

Co-occurring mental disorder and substance use disorder in young people: aetiology, assessment and treatment

Dual diagnosis is one of several terms used to identify individuals diagnosed with a co-occurring mental disorder and substance use disorder. The existence of a dual diagnosis in adolescents is often associated with functional impairment in various life domains, causing physical health problems, relational conflicts, educational/vocational underachievement and legal problems. Dual diagnosis is difficult to treat and can result in tremendous economic burden on healthcare, education and justice systems. It is essential for clinicians caring for young people to be knowledgeable about dual diagnosis to ensure that it is identified early and treated. This article aims to provide an overview of dual diagnosis, increase its awareness and promote a realistic treatment approach.

Variability in Exposure to Subspecialty Rotations During Orthopaedic Residency: A Website-based Review of Orthopaedic Residency Programs

Introduction:

The variability in exposure to various subspecialty rotations during orthopaedic residency across the United States has not been well studied.

Methods:

Data regarding program size, resident's sex, department leadership, university-based status of the program, outsourcing of subspecialty rotation, and geographic location were collected from websites of 151 US allopathic orthopaedic residency programs. The relationship of these factors with the time allotted for various clinical rotations was analyzed.

Results:

The number of residents in a program correlated positively with time allocated for elective rotations (r = 0.57, P = 0.0003). Residents in programs where the program director was a general orthopaedic surgeon spent more time on general orthopaedic rotations (22 versus 9.9 months, P = 0.001). Programs where the program director or chairman was an orthopaedic oncologist spent more time on oncology rotations ([3.8 versus 3 months, P = 0.01] and [3.5 versus 2.7 months, P = 0.01], respectively). Residents in community programs spent more time on adult reconstruction than university-based programs (6.6 versus 5.5 months, P = 0.014). Based on multiple linear regression analysis, time allotted for adult reconstruction (t = 2.29, P = 0.02) and elective rotations (t = 2.43, P = 0.017) was positively associated with the number of residents in the program.

Conclusions:

Substantial variability exists in the time allocated to various clinical rotations during orthopaedic residency. The effect of this variability on clinical competence, trainees' career choices, and quality of patient care needs further study.

The Impact of Block Ambulatory Scheduling on Internal Medicine Residencies: a Systematic Review

BACKGROUND

Over the past decade, nearly half of internal medicine residencies have implemented block clinic scheduling; however, the effects on residency-related outcomes are unknown. The authors systematically reviewed the impact of block versus traditional ambulatory scheduling on residency-related outcomes, including (1) resident satisfaction, (2) resident-perceived conflict between inpatient and outpatient responsibilities, (3) ambulatory training time, (4) continuity of care, (5) patient satisfaction, and (6) patient health outcomes.

METHOD

The authors reviewed the following databases: Ovid MEDLINE, Ovid MEDLINE InProcess, EBSCO CINAHL, EBSCO ERIC, and the Cochrane Library from inception through March 2017 and included studies of residency programs comparing block to traditional scheduling with at least one outcome of interest. Two authors independently extracted data on setting, participants, schedule design, and the outcomes of interest.

RESULTS

Of 8139 studies, 11 studies of fair to moderate methodologic quality were included in the final analysis. Overall, block scheduling was associated with marked improvements in resident satisfaction (n = 7 studies, effect size range - 0.3 to + 0.9), resident-perceived conflict between inpatient and outpatient responsibilities (n = 5, effect size range + 0.3 to + 2.6), and available ambulatory training time (n = 5). Larger improvements occurred in programs implementing short (1 week) ambulatory blocks. However, block scheduling may result in worse physician continuity (n = 4). Block scheduling had inconsistent effects on patient continuity (n = 4), satisfaction (n = 3), and health outcomes (n = 3).

DISCUSSION

Although block scheduling improves resident satisfaction, conflict between inpatient and outpatient responsibilities, and ambulatory training time, there may be important tradeoffs with worse care continuity.

Scope and Nature of Pain- and Analgesia-Related Content of the United States Medical Licensing Examination (USMLE)

Background

"The ongoing opioid crisis lies at the intersection of two substantial public health challenges-reducing the burden of suffering from pain and containing the rising toll of the harms that can result from the use of opioid medications" [1]. Improved pain education for health care providers is an essential component of the multidimensional response to both still-unmet challenges [2,3]. Despite the importance of licensing examinations in assuring competency in health care providers, there has been no prior appraisal of pain and related content within the United States Medical Licensing Examination (USMLE).

Methods

An expert panel developed a novel methodology for characterizing USMLE questions based on pain core competencies and topical and public health relevance.

Results

Under secure conditions, raters used this methodology to score 1,506 questions, with 28.7% (432) identified as including the word "pain." Of these, 232 questions (15.4% of the 1,506 USMLE questions reviewed) were assessed as being fully or partially related to pain, rather than just mentioning pain but not testing knowledge of its mechanisms and their implications for treatment. The large majority of questions related to pain (88%) focused on assessment rather than safe and effective pain management, or the context of pain.

Conclusions

This emphasis on assessment misses other important aspects of safe and effective pain management, including those specific to opioid safety. Our findings inform ways to improve the long-term education of our medical and other graduates, thereby improving the health care of the populations they serve.

Normalizing fibromyalgia as a chronic illness

Fibromyalgia (FM) is a complex chronic disease that affects 3-10% of the general adult population and is principally characterized by widespread pain, and is often associated with disrupted sleep, fatigue, and comorbidities, among other symptoms. There are many gaps in our knowledge of FM, such that, compared with other chronic illnesses including diabetes, rheumatoid arthritis, and asthma, it is far behind in terms of provider understanding and therapeutic approaches. The experience that healthcare professionals (HCPs) historically gained in developing approaches to manage and treat patients with these chronic illnesses may help show how they can address similar problems in patients with FM. In this review, we examine some of the issues around the management and treatment of FM, and discuss how HCPs can implement appropriate strategies for the benefit of patients with FM. These issues include understanding that FM is a legitimate condition, the benefits of prompt diagnosis, use of non-drug and pharmacotherapies, patient and HCP education, watchful waiting, and assessing patients by FM domain so as not to focus exclusively on one symptom to the detriment of others. Developing successful approaches is of particular importance for HCPs in the primary care setting who are in the ideal position to provide long-term care for patients with FM. In this way, FM may be normalized as a chronic illness to the benefit of both patients and HCPs.

Education in Nephrology Fellowship: A Survey-Based Needs Assessment

Educational needs assessments for nephrology fellowship training are limited. This study assessed fellows' perceptions of current educational needs and interest in novel modalities that may improve their educational experience and quantified educational resources used by programs and fellows. We distributed a seven-question electronic survey to all United States-based fellows receiving complimentary American Society of Nephrology (ASN) membership at the end of the 2015-2016 academic year in conjunction with the ASN Nephrology Fellows Survey. One third (320 of 863; 37%) of fellows in Accreditation Council for Graduate Medical Education-accredited positions responded. Most respondents rated overall quality of teaching in fellowship as either "good" (37%) or "excellent" (44%), and most (55%) second-year fellows felt "fully prepared" for independent practice. Common educational resources used by fellows included UpToDate, Journal of the American Society of Nephrology/Clinical Journal of the American Society of Nephrology, and Nephrology Self-Assessment Program; others-including ASN's online curricula-were used less often. Fellows indicated interest in additional instruction in several core topics, including home dialysis modalities, ultrasonography, and pathology. Respondents strongly supported interventions to improve pathology instruction and increase time for physiology and clinical review. In conclusion, current nephrology fellows perceive several gaps in training. Innovation in education and training is needed to better prepare future nephrologists for the growing challenges of kidney care.

Primary Care Resident Training for Obesity, Nutrition, and Physical Activity Counseling: A Mixed-Methods Study

National guidelines have been established to support the role of primary care physicians in addressing obesity. Preparing primary care residents to recognize and treat overweight/obesity has been identified as an essential component of postgraduate medical training that is currently lacking. This study aims to identify how primary care residency programs are preparing physicians to counsel about obesity, nutrition, and physical activity (ONPA) and to examine program members' perspectives regarding the place of ONPA counseling in the curriculum, and its relevance in primary care training. Using mixed methods, we collected and analyzed data on 25 family medicine, internal medicine, and obstetrics/gynecology residency programs across Ohio. Programs averaged 2.8 hours of ONPA-related didactics per year. Ten programs (42%) taught techniques for health behavior counseling. Having any ONPA-related didactics was associated with greater counseling knowledge (p = .01) among residents but poorer attitudes (p < .001) and poorer perceived professional norms (p = .004) toward ONPA counseling. Findings from interview data highlighted similar perceived barriers to ONPA counseling across all three specialties but variation in perception of responsibility to provide ONPA counseling. While widespread expectations that primary care physicians counsel their overweight and obese patients prevail, few residency programs provide training to support such counseling.

Yes, It Is Time to Rethink Postgraduate Training Requirements for Licensure!

In his Commentary in this issue, Dr. Freeman asks whether it is time to rethink postgraduate training requirements for licensure. The majority of U.S. states require a minimum of one year of postgraduate residency training to qualify for a medical license. The original rationale for requiring just a single year of training dates back over half a century to the era of a general practitioner completing medical school followed by a rotating internship prior to heading out into independent general practice. Today, however, the requirement for a single year of training for licensure is in direct contrast to the more rigorous requirements for specialty certification, the current trend in medical education toward competency-based training, and the unanimous agreement among national organizations that readiness for independent practice usually takes three to five years of progressive training. The complexity of medical practice today, the rising use of technology, and the rapid explosion of the understanding of medical science raise the important question of whether this licensing requirement is out of sync with state medical boards' goal of protecting the public by licensing only qualified physicians. A national discussion should be held to distinguish clear minimal standards for physician training that protect the public by ensuring that practicing physicians are highly qualified through rigorous training.

Treatment Access Barriers and Disparities Among Individuals with Co-Occurring Mental Health and Substance Use Disorders: An Integrative Literature Review

The purpose of this integrative review is to examine and synthesize extant literature pertaining to barriers to substance abuse and mental health treatment for persons with co-occurring substance use and mental health disorders (COD). Electronic searches were conducted using ten scholarly databases. Thirty-six articles met inclusion criteria and were examined for this review. Narrative review of these articles resulted in the identification of two primary barriers to treatment access for individuals with COD: personal characteristics barriers and structural barriers. Clinical implications and directions for future research are discussed. In particular, additional studies on marginalized sub-populations are needed, specifically those that examine barriers to treatment access among older, non-White, non-heterosexual populations.

Analysis of perception of training in graduates of the Faculty of Medicine at Universidad de Castilla-Mancha

INTRODUCTION

Problem-based learning has been a key component of the teaching method employed at the Faculty of Medicine at the University of Castilla La Mancha (UCLM) in Albacete, Spain since its creation. The aim of this study was to evaluate perceptions of training among residents who graduated from the first three years of the UCLM Degree in Medicine.

METHODS

Using the Jefferson Medical College postgraduate rating form, residents rated their performance in four areas of clinical competency (medical knowledge, data gathering skills, clinical judgment, and professional attitudes) at the beginning of residency training in comparison with colleagues from other faculties. The construct validity of responses was evaluated using Cronbach's alpha and exploratory factor analysis.

RESULTS

Over half the respondents (57.8%) considered that they had received better training than peers from other medical schools, and 98.5% felt that their general performance in the four competencies analyzed was similar or superior to that of their colleagues. Factor analysis revealed two major factors: "the physician as scientist" and "the physician as manager and communicator".

CONCLUSIONS

Our study shows that graduates from the UCLM Faculty of Medicine perceive their training, which is largely based on problem-based learning, as satisfactory.

Primary Care Residents' Knowledge, Attitudes, Self-Efficacy, and Perceived Professional Norms Regarding Obesity, Nutrition, and Physical Activity Counseling

BACKGROUND

Obesity and being overweight are both significant risk factors for multiple chronic conditions. Primary care physicians are in a position to provide health behavior counseling to the majority of US adults, yet most report insufficient training to deliver effective counseling for obesity.

OBJECTIVE

To assess the degree to which residents training in adult primary care programs are prepared to provide obesity, nutrition, and physical activity (ONPA) counseling.

METHODS

Senior residents (postgraduate year [PGY]-3 and PGY-4) from 25 Ohio family medicine, internal medicine, and obstetrics and gynecology programs were surveyed regarding their knowledge about obesity risks and effective counseling, as well as their attitudes, self-efficacy, and perceived professional norms toward ONPA counseling. We examined summary scores, and used regression analyses to assess associations with resident demographics and training program characteristics.

RESULTS

A total of 219 residents participated (62% response rate). Mean ONPA counseling knowledge score was 50.8 (± 15.6) on a 0 to 100 scale. Specialty was associated with counseling self-efficacy (P < .001) and perceived norms (P = .002). Residents who reported having engaged in an elective rotation emphasizing ONPA counseling had significantly higher self-efficacy and more positive attitudes and professional norms scores.

CONCLUSIONS

Our findings suggest that primary care residents' knowledge of ONPA assessment and management strategies has room for improvement. Attitudes, self-efficacy, and perceived norms also are low and vary by training program characteristics. A deeper understanding of curricula associated with improved performance in these domains could inform interventions to enhance residents' ONPA counseling skills and prevent chronic disease.

New graduates' perceptions of preparedness to provide speech-language therapy services in general and dysphagia services in particular

BACKGROUND

Upon graduation, newly qualified speech-language therapists are expected to provide services independently. This study describes new graduates' perceptions of their preparedness to provide services across the scope of the profession and explores associations between perceptions of dysphagia theory and clinical learning curricula with preparedness for adult and paediatric dysphagia service delivery.

METHODS

New graduates of six South African universities were recruited to participate in a survey by completing an electronic questionnaire exploring their perceptions of the dysphagia curricula and their preparedness to practise across the scope of the profession of speech-language therapy.

RESULTS

Eighty graduates participated in the study yielding a response rate of 63.49%. Participants perceived themselves to be well prepared in some areas (e.g. child language: 100%; articulation and phonology: 97.26%), but less prepared in other areas (e.g. adult dysphagia: 50.70%; paediatric dysarthria: 46.58%; paediatric dysphagia: 38.36%) and most unprepared to provide services requiring sign language (23.61%) and African languages (20.55%). There was a significant relationship between perceptions of adequate theory and clinical learning opportunities with assessment and management of dysphagia and perceptions of preparedness to provide dysphagia services.

CONCLUSION

There is a need for review of existing curricula and consideration of developing a standard speech-language therapy curriculum across universities, particularly in service provision to a multilingual population, and in both the theory and clinical learning of the assessment and management of adult and paediatric dysphagia, to better equip graduates for practice.

Attitudes about providing HIV care: voices from publicly funded clinics in California

BACKGROUND

As the enactment of health care reform becomes a reality in the USA, it has been widely predicted that HIV+ patients will increasingly be cared for by primary care physicians (PCPs), many of whom lack the experience to deliver full-spectrum HIV care.

OBJECTIVE

To describe PCPs' preparedness for an influx of HIV+ patients.

METHODS

This qualitative study included interviews with 20 PCPs from community health centres in California. We inquired about clinicians' experiences with HIV, their strategies for dealing with unfamiliar aspects of medicine and their management of complicated patients. We also identified the clinicians' preferred types of information and consultation resources.

RESULTS

PCPs are not yet comfortable as providers of comprehensive HIV care; however, they are dedicated to delivering excellent care to all of their patients, regardless of disease process. Although they prefer to refer HIV+ patients to centres of excellence, they are willing to adopt full responsibility when necessary and believe they can deliver high-quality HIV care if provided with adequate consultation and informational resources.

CONCLUSIONS

The Affordable Care Act will insure an estimated 20000 more HIV+ patients in California. With a dwindling supply of HIV specialists, many of these patients will be principally cared for by PCPs. PCPs will go to great lengths to ensure that HIV+ patients receive superior care, but they need the support of HIV specialists to expand their skills. Priority should be given to ensuring that expert consultation is widely available to PCPs who find themselves caring for HIV+ patients.

Knowledge, attitudes and beliefs about chronic noncancer pain in primary care: a Canadian survey of physicians and pharmacists

BACKGROUND

Primary care providers' knowledge, attitudes and beliefs (KAB) regarding chronic noncancer pain (CNCP) are a barrier to optimal management.

OBJECTIVES

To evaluate and identify the determinants of the KAB of primary care physicians and pharmacists, and to document clinician preferences regarding the content and format of a continuing education program (CEP).

METHOD

Physicians and pharmacists of 486 CNCP patients participated. Physicians completed the original version of the KnowPain-50 questionnaire. Pharmacists completed a modified version. A multivariate linear regression model was developed to identify the determinants of their KAB.

RESULTS

A total of 137 of 387 (35.4%) physicians and 110 of 278 (39.5%) pharmacists completed the survey. Compared with the physicians, the pharmacists surveyed included more women (64% versus 38%) and had less clinical experience (15 years versus 26 years). The mean KnowPain-50 score was 69.3% (95% CI 68.0% to 70.5%) for physicians and 63.8% (95% CI 62.5% to 65.1%) for pharmacists. Low scores were observed on all aspects of pain management: initial assessment (physicians, 68.3%; pharmacists, 65.4%); definition of treatment goals and expectations (76.1%; 61.6%); development of a treatment plan (66.4%; 59.0%); and reassessment and management of longitudinal care (64.3%; 53.1%). Ten hours of reported CEP sessions increased the KAB score by 0.3 points. All clinicians considered a CEP for CNCP to be essential. Physicians preferred an interactive format, while pharmacists had no clear preferences.

CONCLUSION

A CEP to improve primary care providers' knowledge and competency in managing CNCP, and to reduce false beliefs and inappropriate attitudes regarding CNCP is relevant and perceived as necessary by clinicians.

Patient–Physician Role Relationships and Patient Activation

The goals of this article were to empirically describe how racial and ethnic minorities compare with Whites in terms of their role relationships with physicians and examine how differences in those relationships are associated (positively or negatively) with patient activation for minority groups, relative to Whites. Based on analysis of survey data collected from a random sample of 8,140 individuals with chronic illness, we found that both Blacks and Hispanics generally perceive their role relationships with physicians to be less equitable than do Whites and that the benefits to minorities from more equitable role relationships with physicians are not uniform across dimensions of patient–physician relationships or racial and ethnic subgroups. Based on these findings, we submit that race and ethnicity should be considered in the development and assessment of tailored interventions to improve activation.

Pain medicine: The case for an independent medical specialty and training programs

Over the last 30 years, pain has become one of the most dynamic areas of medicine and a public health issue. According to a recent Institute of Medicine report, pain affects approximately 100 million Americans at an estimated annual economic cost of $560 to $635 billion and is poorly treated overall. The American Board of Medical Specialties (ABMS) recognizes a pain subspecialty, but pain care delivery has struggled with increasing demand and developed in an inconsistent and uncoordinated fashion. Pain education is insufficient and highly variable. Multiple pain professional organizations have led to fragmentation of the field and lack of interdisciplinary agreement, resulting in confusion regarding who speaks for pain medicine. In this Perspective, the authors argue that ABMS recognition of pain medicine as an independent medical specialty would provide much needed structure and oversight for the field and would generate credibility for the specialty and its providers among medical peers, payers, regulatory and legislative agencies, and the public at large. The existing system, managed by three ABMS boards, largely excludes other specialties that contribute to pain care, fails to provide leadership from a single professional organization, provides suboptimal training exposure to pain medicine, and lengthens training, which results in inefficient use of time and educational resources. The creation of a primary ABMS conjoint board in pain medicine with its own residency programs and departments would provide better coordinated training, ensure the highest degree of competence of pain medicine specialists, and improve the quality of pain care and patient safety.

Multifaceted longitudinal study of surgical resident education, quality of life, and patient care before and after July 2011

OBJECTIVES

Resident duty-hour regulatory changes in July 2011 led to dramatic modifications in the structure of many surgical training programs in the United States. These changes were hypothesized to have effects on the quality of life and education of residents, and the patient care they deliver. Our study aims to measure changes in these domains among junior and senior residents before and after implementation of the latest regulations.

DESIGN

Longitudinal cohort study comparing objective and subjective metrics of education, patient care, and quality of life among all surgical residents at one institution.

SETTING

Tertiary academic medical center.

PARTICIPANTS

All residents in the Department of Surgery over 2 years (n = 97) were included. The included electronic survey had 30 and 36 responses in 2011 and 2012, respectively (overall 68% response rate).

RESULTS

Operative cases increased for residents at all postgraduate year levels. No significant differences in in-training examination scores were observed. Comparison of subjective data from the program evaluation and developed survey revealed a significant decrease in perception of resident clinical skill development (4.31/5 in 2011 to 4.15/5 in 2012, p = 0.02). Residents reported decreased quality of operative experiences (83% to 59%, p = 0.04), and less independence evaluating patient problems (90% to 61%, p < 0.01). Levels of burnout were high in the entire group, but decreased significantly over the study period (93% and 75% in 2011 and 2012, respectively, p = 0.05), with the largest difference seen in individuals with "high burnout" (43% and 11%, in 2011 and 2012, respectively, p < 0.01). Residents met criteria for "sleepiness" before and after the 16-hour rule implementation (68% and 67%, in 2011 and 2012, respectively, p = 0.92).

CONCLUSIONS

Following the July 2011 duty-hour changes, surgical residents report a negative effect on their education, with decreased clinical skill progression and perceptions of operative experience quality and patient care independence. Improvements in quality of life metrics, including burnout, were observed.

Teaching resident physicians chronic disease management: simulating a 10-year longitudinal clinical experience with a standardized dementia patient and caregiver

BACKGROUND

Education for all physicians should include specialty-specific geriatrics-related and chronic disease-related topics.

OBJECTIVE

We describe the development, implementation, and evaluation of a chronic disease/geriatric medicine curriculum designed to teach Accreditation Council for Graduate Medical Education core competencies and geriatric medicine competencies to residents by using longitudinal encounters with a standardized dementia patient and her caregiver daughter.

INTERVENTION

Over 3 half-day sessions, the unfolding standardized patient (SP) case portrays the progressive course of dementia and simulates a 10-year longitudinal clinical experience between residents and a patient with dementia and her daughter. A total of 134 residents participated in the University of Cincinnati-based curriculum during 2007-2010, 72% of whom were from internal medicine (79) or family medicine (17) residency programs. Seventy-five percent of participants (100) said they intended to provide primary care to older adults in future practice, yet 54% (73) had little or no experience providing medical care to older adults with dementia.

RESULTS

Significant improvements in resident proficiency were observed for all self-reported skill items. SPs' evaluations revealed that residents' use of patient-centered language and professionalism significantly improved over the 3 weekly visits. Nearly all participants agreed that the experience enhanced clinical competency in the care of older adults and rated the program as "excellent" or "above average" compared to other learning activities.

CONCLUSIONS

Residents found this SP-based curriculum using a longitudinal dementia case realistic and valuable. Residents improved in both self-perceived knowledge of dementia and the use of patient-centered language and professionalism.

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.

An evaluation of internal medicine residency continuity clinic redesign to a 50/50 outpatient-inpatient model

BACKGROUND

There have been recent calls for improved internal medicine outpatient training, yet assessment of clinical and educational variables within existing models is lacking.

OBJECTIVE

To assess the impact of clinic redesign from a traditional weekly clinic model to a 50/50 outpatient-inpatient model on clinical and educational outcomes.

DESIGN

Pre-intervention and post-intervention study intervals, comparing the 2009-2010 and 2010-2011 academic years.

PARTICIPANTS

Ninety-six residents in a Primary Care Internal Medicine site of a large academic internal medicine residency program who provide care for > 13,000 patients.

INTERVENTION

Continuity clinic redesign from a traditional weekly clinic model to a 50/50 model characterized by 50 % outpatient and 50 % inpatient experiences scheduled in alternating 1 month blocks, with twice weekly continuity clinic during outpatient months and no clinic during inpatient months.

MAIN MEASURES

1) Clinical outcomes (panel size, patient visits, adherence with chronic disease and preventive service guidelines, continuity of care, patient satisfaction, and perceived safety/teamwork in clinic); 2) Educational outcomes (attendance at teaching conference, resident and faculty satisfaction, faculty assessment of resident clinic performance, and residents' perceived preparedness for outpatient management).

RESULTS

Redesign was associated with increased mean panel size (120 vs. 137.6; p ≤ 0.001), decreased continuity of care (63 % vs. 48 % from provider perspective; 61 % vs. 51 % from patient perspective; p ≤  0.001 for both; team continuity was preserved), decreased missed appointments (12.5 % vs. 10.9 %; p ≤  0.01), improved perceived safety and teamwork (3.6 vs. 4.1 on 5-point scale; p ≤  0.001), improved mean teaching conference attendance (57.1 vs. 64.4; p ≤  0.001), improved resident clinic performance (3.6 vs. 3.9 on 5-point scale; p ≤  0.001), and little change in other outcomes.

CONCLUSION

Although this model requires further study in other settings, these results suggest that a 50/50 model may allow residents to manage more patients while enhancing the climate of teamwork and safety in the continuity clinic, compared to traditional models. Future work should explore ways to preserve continuity of care within this model.

Which skills are associated with residents' sense of preparedness to manage chronic pain?

OBJECTIVE

To identify gaps in residents' confidence and knowledge in managing chronic nonmalignant pain (CNMP) and to explore whether specific skills or pain knowledge was associated with global preparedness to manage CNMP.

DESIGN

Cross-sectional web-based survey.

SETTING AND PARTICIPANTS

Internal medicine residents in Bronx, NY.

MAIN OUTCOME MEASURES

The authors assessed the following: 1) confidence in skills within the following four content areas: physical examination, diagnosis, treatment, and safer opioid prescribing; 2) pain-related knowledge on a 16-item scale; and 3) global preparedness to manage CNMP (agreement with, "I feel prepared to manage CNMP"). Gaps in confidence were skills in which fewer than 50 percent reported confidence. Gaps in knowledge were items in which fewer than 50 percent answered correctly. Using logistic regression, the authors examined whether skills or knowledge was associated with global preparedness.

RESULTS

Of 145 residents, 92 (63 percent) responded. Gaps in confidence included diagnosing fibromyalgia, performing corticosteroid injections, and using pain medication agreements. Gaps in knowledge included pharmacotherapy for neuropathic pain and interpreting urine drug test results. Twenty-four residents (26 percent) felt globally prepared to manage CNMP. Confidence using pain medication agreements (adjusted odds ratio [AOR], 5.99; 95% confidence interval [CI], 2.02-17.75), prescribing long-acting opioids (AOR, 5.85; 95% CI, 2.00-17.18), and performing corticosteroid injection of the knee (AOR, 5.76; 95% CI, 1.16-28.60]) were strongly associated with global preparedness.

CONCLUSIONS

Few internal medicine residents felt prepared to manage CNMP. Our findings suggest that educational interventions to improve residents' preparedness to manage CNMP should target complex pain syndromes (eg, fibromyalgia and neuropathic pain), safer opioid prescribing practices, and alternatives to opioid analgesics.

An alumni survey as a needs assessment for curriculum improvement in obstetrics and gynecology

BACKGROUND

The Accreditation Council for Graduate Medical Education requirements recommend using outside measures to perform annual residency program evaluations to identify areas for program improvement.

OBJECTIVE

The aim of the study was to identify areas for residency program improvement via an alumni survey.

METHODS

An anonymous online survey was sent to the last 10 years of graduates from our obstetrics and gynecology residency program.

RESULTS

Response rate was 63% (34 of 54). All respondents reported being comfortable serving as gynecologic consultants. More than 75% (26 of 54) reported being comfortable performing abdominal hysterectomies, vaginal hysterectomies, basic and complex laparoscopies, and vaginal surgery. Regarding management of urologic injuries, the participants' responses varied, with 58% (20 of 34) reporting they felt prepared, 21% (7 of 34) with neutral responses, and 21% (7 of 34) reporting they felt unprepared. For total laparoscopic hysterectomy, 65% (22 of 34) reported feeling prepared, 29% (10 of 34) reported they felt unprepared, and 9% (3 of 34) reported they felt neutral. All respondents indicated that he or she would still choose the obstetrics and gynecology residency program at the University of Michigan.

CONCLUSION

An alumni survey can provide useful outside measures for training programs to assess their effectiveness in preparing their graduates for independent practice. Results of alumni surveys can provide a blueprint for program improvement.

Confidence in clinical practice of Chinese medicine degree graduates 1 year after graduation: a pilot study

BACKGROUND

The issue of transition from student to practitioner of Chinese medicine (CM) in Australia and other Western countries has received little formal attention. Workforce studies, while not up to date nationally in Australia, suggest that the majority of CM practitioners practice as sole practitioners or in small practices. Data from the state of Victoria suggest that a significant proportion of the CM workforce is relatively new to the profession. It is not known how many graduates successfully enter the workforce and importantly, remain in it.

OBJECTIVES

An initial survey of final-year bachelor degree CM students in Australian education institutions in 2008 suggested that students felt "somewhat" prepared for clinical practice in eight dimensions of clinical practice. The authors conducted a follow-up study to this initial one, seeking to investigate perceptions of confidence in CM graduates in various aspects of clinical practice within the first year of completing their degree.

METHODS

A content-validated survey based on the previous study was distributed to a subset of 30 graduates from the original study cohort who had indicated a willingness to participate in this follow-up survey.

RESULTS

There were a small number of responses (n=12), limiting the usefulness of the quantitative questions. However, some interesting qualitative outcomes from the long-answer part of the survey support findings from the previous study that recent practitioners would like more clinical experience, as well as support in developing their business and interpersonal skills, and the option to participate in a professional mentoring arrangement.

CONCLUSIONS

Results of this study suggest that both education providers and professional associations may be able to play important and complementary roles in assisting CM students to successfully transition into the workforce. If CM is to continue to develop as a profession in Australia, it will be important that more attention be given to how to assist new graduates to successfully transition into and remain in clinical practice.

Patient-physician role relationships and patient activation among individuals with chronic illness

OBJECTIVE

To examine whether chronically ill patients' perceptions of their role relationships with their physicians are associated with levels of patient activation.

DATA SOURCES

Random digit dial survey of 8,140 chronically ill patients and the Area Resource File.

STUDY DESIGN

Cross-sectional, multivariate analysis of the relationship between dimensions of patient-physician role relationships and level of patient activation. The study controlled for variables related to patient demographics, socioeconomic status, health status, and market and family context.

PRINCIPAL FINDINGS

Higher perceived quality of interpersonal exchange with physicians, greater fairness in the treatment process, and more out-of-office contact with physicians were associated with higher levels of patient activation. Treatment goal setting was not significantly associated with patient activation.

CONCLUSION

Patient-physician relationships are an important factor in patients taking a more active role in their health and health care. Efforts to increase activation that focus only on individual patients ignore the important fact that the nature of roles and relationships between provider and patient can shape the behaviors and attitudes of patients in ways that support or discourage patient activation.

Innovations in applied health: evaluating a simulation-enhanced, interprofessional curriculum

BACKGROUND

In response to current trends in healthcare education, teachers at the Michener Institute for Applied Health Sciences implemented a New Curriculum Model (NCM) in 2006, building a curriculum to better transition students from didactic to clinical education. Through the implementation of interprofessional education and simulated clinical scenarios, educators created a setting to develop, contextualize and apply students' skills before entry to the clinical environment.

AIMS

In this pilot study, researchers assessed the impact of the NCM intervention on student preparedness for clinical practicum.

METHODS

A mixed-methods evaluation was conducted, collecting survey assessments and qualitative focus group feedback from clinical educators and students.

RESULTS

Clinical educators identified Michener NCM students to be significantly better prepared for clinical practicum when compared to previous cohorts (p < 0.05%). Students also noted significant improvements as implementation issues were resolved from years one to two of the NCM.

CONCLUSIONS

The infusion of simulation and interprofessional education into Michener's applied health curricula resulted in a significant improvement in clinical preparedness. The Michener NCM bridged the gap previously separating didactic education and clinical practice, transitioning applied health students from trained technicians to more complete health care professionals.

Factors Associated with Willingness to Respond to a Disaster: A Study of Healthcare Workers in a Tertiary Setting

Introduction: Due to recent disasters, disaster planners increasingly are focusing on healthcare worker preparedness and response in the event of a disaster. In this study, factors associated with pediatric healthcare workers’ willingness to respond are identified.

Hypothesis: It was hypothesized that personal factors may affect a pediatric healthcare worker’s willingness to respond to work in the event of a disaster.

Methods: Employees of a tertiary, pediatric care hospital in Los Angeles were asked to complete a brief, 24-question online survey to determine their willingness to respond in the event of a disaster. Information on demographics, employment, disaster-related training, personal preparedness, and necessary resources was collected. A logistic regression model was performed to derive adjusted odds ratios (OR) and their corresponding 95% confidence intervals (95% CI).

Results: Eight hundred seventy-seven pediatric healthcare employees completed the survey (22% response rate). Almost 50% (n = 318) expressed willingness to respond in the event of a disaster. Men were more likely to be willing to respond to a disaster than were women (OR = 2.4; 95%CI = 1.6–3.6), and single/divorced/widowed employees were more willing to respond than married or partnered employees (OR = 1.5; 95%CI = 1.1–2.1). An inverse relationship was observed between number of dependents and willingness to respond (OR = 0.45; 95%CI = 0.25–0.80, ≥3 dependents compared to 0). An inverse dose response relationship between commuting distance and number of necessary resources (ptrend = 0.0485 and 0.0001, respectively) was observed. There was no association between previous disaster experience, disaster training, or personal preparedness and willingness to respond.

Conclusions: Number of dependents and resources were major factors in willingness to respond. Healthcare facilities must clearly communicate their disaster plans as well as any provisions they may make for their employees’ families in order to improve willingness among hospital employees.

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.

Evaluation of a case-based primary care pediatric conference curriculum

BACKGROUND

Our goal was to assess the impact of a standardized residency curriculum in ambulatory pediatrics on residents' participation, satisfaction, and confidence.

METHODS

A case-based curriculum for weekly primary care conference was developed to replace the existing free-form review of topics at the Yale Pediatrics Residency Program. Before the curricular switch, faculty preceptors and members of the academic year 2005-2006 intern class completed surveys designed to measure conference occurrence and resident attendance, participation, satisfaction, and confidence in clinical skills. One year after the curricular switch, identical surveys were completed by faculty preceptors and members of the academic year 2006-2007 intern class.

RESULTS

Faculty surveys indicated that conferences took place significantly more often after the curricular switch. The number of residents at conference each day (3.18 vs 4.50; P < .01) and the percentage who actually spoke during conference (45% vs 82%, P < .01) significantly increased. There were 18 demographically similar interns in each of the 2 classes. Members of the academic year 2006-2007 intern class, having trained exclusively with the standardized curriculum, were significantly more likely to respond favorably to survey items about participation, satisfaction, and confidence. In addition, they were more likely to endorse survey items that reflected explicit goals of the standardized curriculum and the Accreditation Council for Graduate Medical Education core competencies.

CONCLUSION

Implementation of a structured curriculum for ambulatory care improved interns' self-reported participation, satisfaction, and confidence. The primary care conference occurred more dependably after the curricular change, and improvements in attendance and participation were documented. Pediatric residency programs may make better use of conference time in the ambulatory setting through the use of structured, case-based educational material.

An academic-community partnership to improve care for the underserved

Despite the need for a robust primary care workforce, the number of students and residents choosing general internal medicine careers continues to decline. In this article, the authors describe their efforts at the University of California, Davis School of Medicine to bolster interest in internal medicine careers and improve the quality of care for medically underserved populations through a tailored third-year residency track developed in partnership with the Sacramento County Department of Health and Human Services. The Transforming Education and Community Health (TEACH) Program improves continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares residents to provide coordinated care for vulnerable populations. Since its inception in 2005, 25 residents have graduated from the TEACH Program. Compared with national rates, TEACH graduates are more likely to practice general internal medicine and to practice in medically underserved settings. TEACH residents report high job satisfaction and provide equal or higher-quality diabetes care than that indicated by national benchmarks. The authors provide an overview of the TEACH Program, including curriculum details, preliminary outcomes, barriers to continued and expanded implementation, and thoughts about the future of the program.