Do we practice what we preach? A qualitative assessment of resident-preceptor interactions for adherence to evidence-based practice

Why do medical residents prefer paternalistic decision making? An interview study

BACKGROUND

Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice remains limited. We previously showed that residents more often prefer paternalistic decision making than their supervisors. Because both the views of residents on the decision-making process in medical consultations and the reasons for their 'paternalism preference' are unknown, this study explored residents' views on the decision-making process in medical encounters and the factors affecting it.

METHODS

We interviewed 12 residents from various specialties at a large Dutch teaching hospital in 2019-2020, exploring how they involved patients in decisions. All participating residents provided written informed consent. Data analysis occurred concurrently with data collection in an iterative process informing adaptations to the interview topic guide when deemed necessary. Constant comparative analysis was used to develop themes. We ceased data collection when information sufficiency was achieved.

RESULTS

Participants described how active engagement of patients in discussing options and decision making was influenced by contextual factors (patient characteristics, logistical factors such as available time, and supervisors' recommendations) and by limitations in their medical and shared decision-making knowledge. The residents' decision-making behavior appeared strongly affected by their conviction that they are responsible for arriving at the correct diagnosis and providing the best evidence-based treatment. They described shared decision making as the process of patients consenting with physician-recommended treatment or patients choosing their preferred option when no best evidence-based option was available.

CONCLUSIONS

Residents' decision making appears to be affected by contextual factors, their medical knowledge, their knowledge about SDM, and by their beliefs and convictions about their professional responsibilities as a doctor, ensuring that patients receive the best possible evidence-based treatment. They confuse SDM with acquiring informed consent with the physician's treatment recommendations and with letting patients decide which treatment they prefer in case no evidence based guideline recommendation is available. Teaching SDM to residents should not only include skills training, but also target residents' perceptions and convictions regarding their role in the decision-making process in consultations.

Impact of deliberate practice on evidence-based medicine attitudes and behaviours of health care professionals

INTRODUCTION

Although evidence-based medicine (EBM) teaching activities may improve short-term EBM knowledge and skills, they have little long-term impact on learners' EBM attitudes and behaviour. This study examined the effects of learning EBM through stand-alone workshops or various forms of deliberate EBM practice.

METHODS

We assessed EBM attitudes and behaviour with the evidence based practice inventory questionnaire, in paediatric health care professionals who had only participated in a stand-alone EBM workshop (controls), participants with a completed PhD in clinical research (PhDs), those who had completed part of their paediatric residency at a department (Isala Hospital) which systematically implemented EBM in its clinical and teaching activities (former Isala residents), and a reference group of paediatric professionals currently employed at Isala's paediatric department (current Isala participants).

RESULTS

Compared to controls (n = 16), current Isala participants (n = 13) reported more positive EBM attitudes (p < 0.01), gave more priority to using EBM in decision making (p = 0.001) and reported more EBM behaviour (p = 0.007). PhDs (n = 20) gave more priority to using EBM in medical decision making (p < 0.001) and reported more EBM behaviour than controls (p = 0.016).

DISCUSSION

Health care professionals exposed to deliberate practice of EBM, either in the daily routines of their department or by completing a PhD in clinical research, view EBM as more useful and are more likely to use it in decision making than their peers who only followed a standard EBM workshop. These findings support the use of deliberate practice as the basis for postgraduate EBM educational activities.

The Ambulatory Teaching Minute: Development of Brief, Case-Based, Evidence-Based Medicine Exercises for the Internal Medicine Resident Continuity Clinic

INTRODUCTION

There are limited data on best approaches for evidence-based medicine (EBM) teaching to residents in busy continuity clinic practices. Ambulatory Teaching Minute (ATM) exercises were designed to deliver brief, case-based, faculty-facilitated teaching to residents on high-yield ambulatory EBM topics.

METHODS

I developed four ATM exercises, with each one-page handout containing a clinical case, a guided discussion of a research question and study design sparked by the case, a synopsis of a recent research article addressing this question, and a teaching guide for facilitation. Internal medicine residents received these ATM exercises over the course of their monthlong ambulatory block. Surveys that assessed resident engagement were obtained from faculty-facilitators (N = 4) and residents (N = 6) at the end of the ambulatory block.

RESULTS

Residents were actively engaged in the exercise, with an average engagement score of 3.81 out of 5. Most respondents reported ATM exercises taking 6-10 minutes. The majority of respondents felt ATMs could be realistically completed once per week.

DISCUSSION

In this preliminary assessment of a new tool for EBM teaching in clinic, positive engagement scores among preceptors and residents highlight the potential of ATMs to efficiently and effectively address EBM topics during limited teaching time in clinic.

Implementing evidence-based medicine in a busy general hospital department: results and critical success factors

Implementing evidence-based medicine (EBM) in a busy hospital department is challenging, but when successful, may contribute to quality of care. This paper is a narrative review of the successes and challenges of deliberate implementation of EBM in a paediatric department in a general teaching hospital in Zwolle, the Netherlands. Key elements in this project were providing basic EBM education to the entire team of consultants and nurse practitioners, structurally embedding EBM activities into our weekly schedule and development of local practice guidelines. This deliberate practice of EBM principles has changed the way we treat common paediatric problems. It likely reduced unwarranted practice variation and promoted a reserved attitude towards the use of unnecessary diagnostics, which might improve delivery of effective, cost-conscious care. The project also positively influenced our group culture and learning environment. In accordance with previous reports, lack of time and reluctance to change routines and habits hindered the practice of EBM in our department. In our experience, these barriers can be overcome by promoting a team-wide endorsement of EBM, a willingness to acknowledge uncertainty and by deliberate practice. If these can be achieved, systematic application of EBM principles in a busy hospital department is feasible and worthwhile.

Impact of a Multifaceted and Clinically Integrated Training Program in Evidence-Based Practice on Knowledge, Skills, Beliefs and Behaviour among Clinical Instructors in Physiotherapy: A Non-Randomized Controlled Study

Background and Purpose

Physiotherapists practicing at clinical placement sites assigned the role as clinical instructors (CIs), are responsible for supervising physiotherapy students. For CIs to role model evidence-based practice (EBP) they need EBP competence. The aim of this study was to assess the short and long term impact of a six-month multifaceted and clinically integrated training program in EBP on the knowledge, skills, beliefs and behaviour of CIs supervising physiotherapy students.

Methods

We invited 37 CIs to participate in this non-randomized controlled study. Three self-administered questionnaires were used pre- and post-intervention, and at six-month follow-up: 1) The Adapted Fresno test (AFT), 2) the EBP Belief Scale and 3) the EBP Implementation Scale. The analysis approach was linear regression modeling using Generalized Estimating Equations.

Results

In total, 29 CIs agreed to participate in the study: 14 were invited to participate in the intervention group and 15 were invited to participate in the control group. One in the intervention group and five in the control group were lost to follow-up. At follow-up, the group difference was statistically significant for the AFT (mean difference = 37, 95% CI (15.9 -58.1), p<0.001) and the EBP Beliefs scale (mean difference = 8.1, 95% CI (3.1 -13.2), p = 0.002), but not for the EBP Implementation scale (mean difference = 1.8. 95% CI (-4.5-8.1), p = 0.574). Comparing measurements over time, we found a statistically significant increase in mean scores related to all outcome measures for the intervention group only.

Conclusions

A multifaceted and clinically integrated training program in EBP was successful in improving EBP knowledge, skills and beliefs among CIs. Future studies need to ensure long-term EBP behaviour change, in addition to assessing CIs’ abilities to apply EBP knowledge and skills when supervising students.

Screening tests among family doctors: do we do as we preach?

OBJECTIVE

To assess the attitudes and practices of family doctors from Southern Israel and their relatives concerning screening tests and disease prevention.

STUDY DESIGN

Cross-sectional survey.

METHODS

Personal interview using a questionnaire that included sociodemographic data and questions related to family doctors' compliance with screening tests for early detection.

RESULTS

One hundred and thirty-eight of 226 eligible doctors (61%) participated in the study, and 81 of them were female (58.7%). Most of the doctors (n = 82; 59.4%) reported a strong belief in the importance of screening tests, but only 27.5% (n = 38) actually underwent these tests themselves. The main reason for non-compliance was lack of time (n = 50; 55.6%). Older doctors (age ≥50 years) were more likely to have undergone lipidograms than younger doctors (P = 0.013). There were no significant differences in the attitudes of family medicine residents and experts in attitudes to screening tests. Only 64 (46.4%) doctors had received an influenza vaccination over the previous year, and this was significantly more common among residents than experts (P = 0.01).

CONCLUSIONS

Family doctors, who are supposed to be role models, believe that screening tests for disease prevention and health promotion are important, but do not undergo most of the recommended tests themselves.

Questionnaire survey of physicians: Design and practical use in nephrology

As medicine grows in complexity, it is imperative for physicians to update their knowledge base and practice to reflect current standards of care. Postgraduate training offers a golden opportunity for resident physicians to create a strong foundation of concepts in medicine. There is a need for assessing the knowledge of residents regarding established clinical practice guidelines and their perceptions regarding patient care and management. In this paper, we review how questionnaire surveys can be designed and applied to identify significant gaps in resident knowledge and inappropriate attitudes and beliefs. This evaluation has important implications for program directors who can then initiate measures to improve resident education. Such efforts during residency training have the potential of improving patient outcomes. We discuss the design of the questionnaire, its pre-testing and validity measures, online distribution, efficient response collection, data analysis, and possible future research. Finally, we illustrate this method of educational research with a questionnaire survey designed to measure the awareness of chronic kidney disease among internal medicine residents.

Measuring progressive independence with the resident supervision index: theoretical approach

BACKGROUND

Graduate medical education is based on an on-the-job training model in which residents provide clinical care under supervision. The traditional method is to offer residents graduated levels of responsibility that will prepare them for independent practice. However, if progressive independence from supervision exceeds residents' progressive professional development, patient outcomes may be at risk. Leaders in graduate medical education have called for "optimal" supervision, yet few studies have conceptually defined what optimal supervision means and whether optimal care is theoretically compatible with progressive independence, nor have they developed a test for progressive independence.

OBJECTIVE

This research develops theory and analytic models as part of the Resident Supervision Index to quantify the intensity of supervision.

METHODS

We introduce an explicit set of assumptions for an ideal patient-centered theory of optimal supervision of resident-provided care. A critical assumption is that informed attending staff will use available resources to optimize patient outcomes first and foremost, with residents gaining clinical competencies by contributing to optimal care. Next, we derive mathematically the consequences of these assumptions as theoretical results.

RESULTS

Under optimal supervision, (1) patient outcome is expected to be no worse than if residents were not involved, (2) supervisors will avoid undersupervising residents (when patients are at increased risk for poor outcomes) or oversupervising residents (when residents miss clinical opportunities to practice care), (3) optimal patient outcomes will be compatible with progressive independence, (4) progressive development can be inferred from progressive independence whenever residents contribute to patient care, and (5) analytic models that test for progressive independence will emphasize adjusting the association between length of graduate medical education training and supervision for case complexity and clinic workload, but not patient health outcomes.

CONCLUSION

An explicit theoretical framework is critical to measure scientifically progressive independence from supervision using graduate medical education data.