Addressing the service versus education conflicts created by residency training in ambulatory care settings

Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care

PURPOSE

The authors previously found that attending physicians conceptualize hospital admission purpose according to 3 perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams.

METHOD

Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis.

RESULTS

The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge focused vs optimization focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspectives, using authority to shut down and redirect discussion. Trainees' maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover).

CONCLUSIONS

Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and to trainees participating in covert maneuvers, potentially affecting trust and professional identify development.

Clinical teaching and supervision in postgraduate psychiatry training: the trainee perspective

OBJECTIVE

We aimed to explore psychiatry trainees' perspectives on clinical teaching and supervision as well as how this might be improved.

METHOD

New Zealand trainees ( n=51) completed online the Maastricht Clinical Teaching Questionnaire (MCQT) and three open-ended questions.

RESULTS

The majority rated 'agree' or 'strongly agree' to all items of the MCQT. Weaknesses in the feedback process including observation, feedback provision, and formulating learning goals were highlighted. College training requirements and workplace environment were identified as factors impacting on clinical teaching and supervision.

CONCLUSIONS

A model was proposed to enhance awareness of the various factors involved in the feedback process.

Service vs education: situational and perceptional differences in surgery residency

OBJECTIVE

This study determined whether situational or perceptional differences exist when trying to define what constitutes "service" and "education" in surgery residency in relation to the Accreditation Council of Graduate Medical Education (ACGME) survey.

DESIGN

An institutional review board-approved, single institute, cross-sectional study was conducted through a survey. Participants were asked to rate common resident tasks. Participants were also asked general questions regarding "service" and "education."

SETTING

Wright State University surgery program, Dayton, OH.

PARTICIPANTS

The study included 69 participants, which included medical students (19), residents (26), nurses/advanced practitioners (14), and attending surgeons (10).

RESULTS

A significantly high number of attending surgeons reported that writing a history and physical examination is educational compared with residents and students. Similar results were found regarding talking with patients/families. Drawing blood and starting peripheral intravenous access were universally rated as service tasks. For laparoscopic cholecystectomy, when the resident had done one previously, it was universally thought educational. When the resident had done more, most attending surgeons thought the task educational, but residents and students thought it much less educational. When analyzing only residents, in talking with families, most interns rated this as service, whereas postgraduate years 2 and 3 reported it as more educational and postgraduate years 4 and 5 ranked it equally as service and educational. Similar results were seen in answering nursing phone calls and writing admission orders. Residents (88%) and attending surgeons (90%) agreed that service is part of residency training. Only 40% of residents, however, stated they know what the term "service" means in regard to the ACGME survey. Overall, 80% of attending surgeons and 44% of residents agree that "service" has not been well defined by the ACGME.

CONCLUSIONS

Situational and perceptional differences do exist regarding "service" and "education" in our program, and most participants are unclear about the terms. As the definitions are situational and change with the person queried, then should this be the ACGME standard to assess programs and issue citations?

Competency is not enough: integrating identity formation into the medical education discourse

Despite the widespread implementation of competency-based medical education, there are growing concerns that generally focus on the translation of physician roles into "measurable competencies." By breaking medical training into small, discrete, measurable tasks, it is argued, the medical education community may have emphasized too heavily questions of assessment, thereby missing the underlying meaning and interconnectedness of how physician roles shape future physicians. To address these concerns, the authors argue that an expanded approach be taken that includes a focus on professional identity development. The authors provide a conceptual analysis of the issues and language related to a broader focus on understanding the relationship between the development of competency and the formation of identities during medical training. Including identity alongside competency allows a reframing of approaches to medical education away from an exclusive focus on "doing the work of a physician" toward a broader focus that also includes "being a physician." The authors consider the salient literature on identity that can inform this expanded perspective about medical education and training.

Productivity vs. training in primary care: analysis of hospitals and health centers in New York City

This paper examines the indirect costs of primary care residency in terms of ambulatory care site productivity and the influence of graduate medical education (GME) subsidies on the employment of primary care residents. Using a sample of hospitals and health centers in New York City (NYC), we find that most facilities employ significantly more primary care residents relative to nonresident primary care physicians than would be dictated by cost-minimizing behavior in the production of primary care. We also find evidence that New York's GME subsidy encourages the "overemployment" of residents, while the Medicare GME subsidy does not. We conclude that the trade-off between productivity and teaching is more serious in primary care than in inpatient settings, and that facilities heavily involved in ambulatory care teaching will be at a competitive disadvantage if GME subsidies are not targeted specifically for primary care.