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Matchett CL, Nordhues HC, Bashir MU, Merry SP, Sawatsky AP. Residents' Reflections on Cost-Conscious Care after International Health Electives: A Single-Center Qualitative Study. J Gen Intern Med 2023; 38:42-48. [PMID: 35411536 PMCID: PMC9849602 DOI: 10.1007/s11606-022-07556-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/30/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC). OBJECTIVE The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC. DESIGN The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees' IHE experiences to characterize their perceptions of HVCCC. PARTICIPANTS The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020. APPROACH The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC. KEY RESULTS GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills. CONCLUSIONS IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees' ideology of and commitment to HVCCC practices.
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Affiliation(s)
- Caroline L Matchett
- Internal Medicine Residency Program, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA.
| | - Hannah C Nordhues
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Usmaan Bashir
- Division of General Medicine, Geriatrics and Palliative Care, University of Virginia Health, Charlottesville, VA, USA
| | - Stephen P Merry
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Adam P Sawatsky
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Fischer KA, Anand S, Walling A, Larson SM, Glaspy J. Cost-Health Literacy as an Educational Objective in Fellowship Training. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:1479-1485. [PMID: 33761118 DOI: 10.1007/s13187-021-01987-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 06/12/2023]
Abstract
Physicians are encouraged to communicate with their patients about financial concerns, but are infrequently taught skills necessary to do so. This study describes a curriculum for oncology fellows aimed to improve skills of cost-health literacy, and provides assessment of the curriculum impact on self-perceived cost communication practices. Oncology fellows at a large academic program in 2019 participated in a cost-health literacy curriculum over 3 months. The curriculum consisted of a didactic on financial toxicity (45 min), a problem-based learning case highlighting financial toxicity risk factors and areas for intervention (30 min), and a group discussion (30 min) to review and consolidate strategies to navigate financial toxicity in direct patient care. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Of 19 participants, 16 completed both the pre-survey and post-survey and were included in the analysis. After the intervention, participants were more likely to report comfort discussing out-of-pocket costs (50% vs. 19%, p = 0.002) and to feel they could help a patient experiencing financial toxicity (62% vs. 6%, p = 0.005). There was no improvement in the subjective assessment of patient financial distress (57% v 50%, p = 0.759). Oncology fellows can improve self-reported cost-health literacy skills through participation in a targeted, brief curriculum. Further studies are warranted to determine how this approach can be applied in other settings and if it objectively impacts cost communication practices.
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Affiliation(s)
- Katrina A Fischer
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA.
- 200 UCLA Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA.
| | - Sidharth Anand
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
| | - Anne Walling
- Department of Medicine (Division of General Internal Medicine & Health Services Research), UCLA School of Medicine, Los Angeles, CA, USA
| | - Sarah M Larson
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
| | - John Glaspy
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
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Stevens R, Galloway TL. Exploring how healthcare teams balance the neurodynamics of autonomous and collaborative behaviors: a proof of concept. Front Hum Neurosci 2022; 16:932468. [PMID: 35966993 PMCID: PMC9365959 DOI: 10.3389/fnhum.2022.932468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Team members co-regulate their activities and move together at the collective level of behavior while coordinating their actions toward shared goals. In parallel with team processes, team members need to resolve uncertainties arising from the changing task and environment. In this exploratory study we have measured the differential neurodynamics of seven two-person healthcare teams across time and brain regions during autonomous (taskwork) and collaborative (teamwork) segments of simulation training. The questions posed were: (1) whether these abstract and mostly integrated constructs could be separated neurodynamically; and, (2) what could be learned about taskwork and teamwork by trying to do so? The taskwork and teamwork frameworks used were Neurodynamic Information (NI), an electroencephalography (EEG) derived measure shown to be a neurodynamic proxy for the pauses and hesitations associated with individual uncertainty, and inter-brain EEG coherence (IBC) which is a required component of social interactions. No interdependency was observed between NI and IBC, and second-by-second dynamic comparisons suggested mutual exclusivity. These studies show that proxies for fundamental properties of teamwork and taskwork can be separated neurodynamically during team performances of ecologically valid tasks. The persistent expression of NI and IBC were not simultaneous suggesting that it may be difficult for team members to maintain inter-brain coherence while simultaneously reducing their individual uncertainties. Lastly, these separate dynamics occur over time frames of 15–30 s providing time for real-time detection and mitigation of individual and collaborative complications during training or live patient encounters.
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Affiliation(s)
- Ronald Stevens
- UCLA School of Medicine, Brain Research Institute, Los Angeles, CA, United States
- The Learning Chameleon, Inc., Culver City, CA, United States
- *Correspondence: Ronald Stevens
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Stachowicz AM, Lambert JW, Hohmann SF, Whiteside JL. Physician and Hospital-level Variation in Hemostatic Agent Use in Benign Gynecologic Procedures. J Minim Invasive Gynecol 2022; 29:1149-1156. [PMID: 35781055 DOI: 10.1016/j.jmig.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/17/2022] [Accepted: 06/25/2022] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE To identify recent nationwide trends in hemostatic agent (HA) use and to explore factors associated with HA use in 3 benign gynecologic surgery contexts: isolated hysterectomy, pelvic organ prolapse repair, and anti-incontinence surgery. DESIGN Retrospective cohort study. SETTING Vizient Clinical Database. PATIENTS Three cohorts of female patients of ≥18 years who underwent benign isolated hysterectomy, pelvic organ prolapse repair, or anti-incontinence procedures were identified between October 2015 and December 2019. INTERVENTIONS HAs are topically applied procoagulant products used for surgical hemostasis and use during included encounters was determined by charge codes. MEASUREMENTS AND MAIN RESULTS Subject-, hospital-, and surgeon-level characteristics and costs were captured. Data were initially analyzed in the aggregate and based on procedure category using the chi-square test or independent samples t tests as appropriate. A bootstrap forest model was used to identify the factors most predictive of HA use. In the final cohort of 184 070 encounters, HAs were used most frequently in hysterectomy (20.7%) and least in anti-incontinence surgery (10.9%). The use of HAs increased from 15.6% in quarter 4 2015 to 19.2% in quarter 4 2019 (p <.001). Encounters using HAs cost more than encounters without HAs ($6271.10 vs $4572.00; p <.001). A bootstrap forest model inclusive of all variables found surgeon and hospital identity cumulatively predictive of 84.9% of HA use, 65.5% and 19.4%, respectively. There was significant variation in HA use among individual surgeons, with 59.9% never using HAs. Of those who did use HAs, 72.8% used HAs more frequently than the mean provider HA use rate (19.4%) and 9.2% used HAs in every case he/she performed. CONCLUSION The significant variation in HA use is driven primarily by physician and hospital identity, suggesting that use of HA in these benign gynecologic surgical contexts may be determined more by physician- and hospital-level factors than patient-level factors.
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Affiliation(s)
- Anne M Stachowicz
- Female Pelvic Medicine and Reconstructive Surgery, The Christ Hospital, (Dr. Stachowicz), Cincinnati, OH.
| | - Joshua W Lambert
- College of Nursing, University of Cincinnati (Dr. Lambert), Cincinnati, OH
| | - Samuel F Hohmann
- Center for Advanced Analytics and Informatics, Vizient Inc. (Dr. Hohmann), Chicago, IL; Department of Health Systems Management, Rush University (Dr. Hohmann), Chicago, IL
| | - James L Whiteside
- Department of Obstetrics and Gynecology, Brody School of Medicine, East Carolina University, Greenville, NC (Dr. Whiteside)
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The Case for Interprofessional Teaching in Graduate Medical Education. ATS Sch 2022; 3:20-26. [PMID: 35634009 PMCID: PMC9131883 DOI: 10.34197/ats-scholar.2021-0091ps] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022] Open
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Zucker J, Carnevale C, Theodore D, Castor D, Meyers K, Gold J, Winetsky D, Scherer M, Cohall A, Gordon P, Sobieszczyk M, Olender S. Attitudes and Perceived Barriers to Sexually Transmitted Infection Screening Among Graduate Medical Trainees. Sex Transm Dis 2021; 48:e149-e152. [PMID: 34110753 PMCID: PMC8462979 DOI: 10.1097/olq.0000000000001396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ABSTRACT Graduate medical training is an opportune time to improve provider delivery of sexually transmitted infection (STI) screening. A survey of trainees found that the majority feel STI screening is their job but identified barriers to successful screening. Training that intentionally address service-specific barriers will be valuable in ending the STI epidemic.
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Affiliation(s)
- Jason Zucker
- Department of Medicine, Division of Infectious Disease, Columbia University Irving Medical Center
| | | | - Deborah Theodore
- Department of Medicine, Division of Infectious Disease, Columbia University Irving Medical Center
| | - Delivette Castor
- Department of Medicine, Division of Infectious Disease, Columbia University Irving Medical Center
| | - Kathrine Meyers
- Aaron Diamond AIDS Research Center at Vagelos College of Physicians and Surgeons
| | - Jeremy Gold
- Department of Internal Medicine, Columbia University Irving Medical Center
| | - Daniel Winetsky
- Department of Medicine, Division of Infectious Disease, Columbia University Irving Medical Center
- HIV Center for Clinical and Behavioral Studies at Columbia University and New York State Psychiatric Institute
| | - Matt Scherer
- Department of Medicine, Division of Infectious Disease, Columbia University Irving Medical Center
| | - Alwyn Cohall
- Department of Pediatrics, Columbia University Irving Medical Center
| | - Peter Gordon
- Department of Medicine, Division of Infectious Disease, Columbia University Irving Medical Center
| | - Magdalena Sobieszczyk
- Department of Medicine, Division of Infectious Disease, Columbia University Irving Medical Center
| | - Susan Olender
- Department of Medicine, Division of Infectious Disease, Columbia University Irving Medical Center
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Alweis R, Donato A, Terry R, Goodermote C, Qadri F, Mayo R. Benefits of developing graduate medical education programs in community health systems. J Community Hosp Intern Med Perspect 2021; 11:569-575. [PMID: 34567443 PMCID: PMC8462840 DOI: 10.1080/20009666.2021.1961381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The creation of new CMS-funded Graduate Medical Education (GME) cap positions by the Consolidated Appropriations Act 2021 offers a unique opportunity for systems in community and rural settings to develop and expand their training programs. This article provides a review of the evidence behind the value proposition for system administrators to foster the growth of GME in community health systems. The infrastructure needed to accredit GME programs may reduce the cost of care for both the patients and the system through improved patient outcomes and facilitation of system efforts to recognize and mitigate social determinants of health. Residents, fellows and medical students expand the capacity of the current healthcare workforce of a system by providing coverage during healthcare emergencies and staffing services in difficult-to-recruit specialties. Those trainees are the nucleus of succession planning for the current medical staff, can facilitate the creation and expansion of service lines, and may elevate the profile of the system through scholarly work and equity and quality improvement activities. While creating GME programs in a community health system may, at first glance, be perceived as cost-prohibitive, there are robust advantages to a system for their creation.
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Affiliation(s)
- Richard Alweis
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Anthony Donato
- Department of Medicine, Tower Health, West Reading, Pennsylvania, United States
| | - Richard Terry
- Academic Affairs, Lake Erie College of Medicine at Elmira, Elmira, New York, United States
| | - Christina Goodermote
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Farrah Qadri
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Robert Mayo
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
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Etherington NB, Clancy C, Jones RB, Dine CJ, Diemer G. Peer Discussion Decreases Practice Intensity and Increases Certainty in Clinical Decision-Making Among Internal Medicine Residents. J Grad Med Educ 2021; 13:371-376. [PMID: 34178262 PMCID: PMC8207905 DOI: 10.4300/jgme-d-20-00948.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 12/22/2020] [Accepted: 03/01/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Team-based decision-making has been shown to reduce diagnostic error, increase clinical certainty, and decrease adverse events. OBJECTIVE This study aimed to assess the effect of peer discussion on resident practice intensity (PI) and clinical certainty (CC). METHODS A vignette-based instrument was adapted to measure PI, defined as the likelihood of ordering additional diagnostic tests, consultations or empiric treatment, and CC. Internal medicine residents at 7 programs in the Philadelphia area from April 2018 to June 2019 were eligible for inclusion in the study. Participants formed groups and completed each item of the instrument individually and as a group with time for peer discussion in between individual and group responses. Predicted group PI and CC scores were compared with measured group PI and CC scores, respectively, using paired t testing. RESULTS Sixty-nine groups participated in the study (response rate 34%, average group size 2.88). The measured group PI score (2.29, SD = 0.23) was significantly lower than the predicted group PI score (2.33, SD = 0.22) with a mean difference of 0.04 (SD = 0.10; 95% CI 0.02-0.07; P = .0002). The measured group CC score (0.493, SD = 0.164) was significantly higher than the predicted group CC score (0.475, SD = 0.136) with a mean difference of 0.018 (SD = 0.073; 95% CI 0.0006-0.0356; P = .022). CONCLUSIONS In this multicenter study of resident PI, peer discussion reduced PI and increased CC more than would be expected from averaging group members' individual scores.
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Affiliation(s)
- Neha Bansal Etherington
- Neha Bansal Etherington, MD, is Assistant Professor of Clinical Medicine and Director of the Internal Medicine Sub-Internship, Lewis Katz School of Medicine, Temple University, Division of Hospital Medicine, Temple University Health System
| | - Caitlin Clancy
- Caitlin Clancy, MD, is Instructor of Clinical Medicine, Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania Health System, Perelman School of Medicine, University of Pennsylvania
| | - R. Benson Jones
- R. Benson Jones, MD, is a Fellow, Division of Endocrinology, Diabetes, and Metabolism, University of Pennsylvania Health System
| | - C. Jessica Dine
- C. Jessica Dine, MD, MHSP, is Associate Professor of Medicine, Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania Health System, and Associate Dean of Faculty Development, Perelman School of Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Gretchen Diemer
- Gretchen Diemer, MD, is Professor of Medicine, Vice Chair of Education for Medicine, and Senior Associate Dean of Graduate Medical Education and Affiliations, Sidney Kimmel Medical College, Thomas Jefferson University
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Zucker J, Carnevale C, Theodore D, Castor D, Meyers K, Gold J, Winetsky D, Scherer M, Cohall A, Gordon P, Sobieszczyk M, Olender S. Attitudes and Perceived Barriers to Routine HIV Screening and Provision and Linkage of Postexposure Prophylaxis and Pre-Exposure Prophylaxis Among Graduate Medical Trainees. AIDS Patient Care STDS 2021; 35:180-187. [PMID: 33901410 PMCID: PMC8106251 DOI: 10.1089/apc.2021.0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
New York City is the metropolitan area in the United States with the highest number of new HIV diagnoses nationwide. The End-The-Epidemic (EtE) initiative calls for identifying persons with HIV who remain undiagnosed, linking and retaining persons living with HIV to maximize viral suppression, and facilitate access to pre-exposure prophylaxis (PrEP) for patients at increased risk of HIV. HIV screening represents the first step to both the primary and secondary HIV prevention cascades. We conducted an online, anonymous, cross-sectional survey of residents at all stages of training within four residency programs at one institution in Northern Manhattan between August 2017 and August 2018. All internal medicine, emergency medicine, obstetrics and gynecology trainees, and pediatrics were invited to complete the survey via email. Of 298 eligible trainees, 142 (48%) completed the survey. Most trainees were aware of the HIV testing law and agreed that HIV testing was their responsibility, but few successfully screened most of their patients. Most trainees were not knowledgeable about non-occupational post-exposure prophylaxis (nPEP) or PrEP, but felt that it was important to provide these services across settings. Barriers to HIV, nPEP, and PrEP varied across specialties. Ending the HIV epidemic will require efforts across clinical specialties. In this survey from an EtE jurisdiction, most trainees felt that it is important to provide HIV prevention services in most settings; however, their knowledge and comfort with HIV prevention services other than testing were low. Barriers varied across specialties, and developing specialty-specific materials for trainees may be beneficial.
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Affiliation(s)
- Jason Zucker
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Caroline Carnevale
- New York-Presbyterian Hospital HIV Prevention Program, New York, New York, USA
| | - Deborah Theodore
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Delivette Castor
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Kathrine Meyers
- Aaron Diamond AIDS Research Center at Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Jeremy Gold
- Department of Internal Medicine and Columbia University Irving Medical Center, New York, USA
| | - Daniel Winetsky
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew Scherer
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Alwyn Cohall
- Department of Pediatrics, Columbia University Irving Medical Center, New York, USA
| | - Peter Gordon
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Magdalena Sobieszczyk
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Susan Olender
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
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Mordang SBR, Leep Hunderfund AN, Smeenk FWJM, Stassen LPS, Könings KD. High-Value, Cost-Conscious Care Attitudes in the Graduate Medical Education Learning Environment: Various Stakeholder Attitudes That Residents Misjudge. J Gen Intern Med 2021; 36:691-698. [PMID: 33140278 PMCID: PMC7947056 DOI: 10.1007/s11606-020-06261-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/21/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND Training residents in delivering high-value, cost-conscious care (HVCCC) is crucial for a sustainable healthcare. A supportive learning environment is key. Yet, stakeholders' attitudes toward HVCCC in residents' learning environment are unknown. OBJECTIVE We aimed to measure stakeholders' HVCCC attitudes in residents' learning environment, compare these with resident perceptions of their attitudes, and identify factors associated with attitudinal differences among each stakeholder group. DESIGN We conducted a cross-sectional survey across the Netherlands between June 2017 and December 2018. PARTICIPANTS Participants were 312 residents, 305 faculty members, 53 administrators, and 1049 patients from 66 (non)academic hospitals. MAIN MEASURES Respondents completed the Maastricht HVCCC Attitude Questionnaire (MHAQ), containing three subscales: (1) high-value care, (2) cost incorporation, (3) perceived drawbacks. Additionally, resident respondents estimated the HVCCC attitudes of other stakeholders, and answered questions on job demands and resources. Univariate and multivariate analyses were used to analyze data. KEY RESULTS Attitudes differed on all subscales: faculty and administrators reported more positive HVCCC attitudes than residents (p ≤ 0.05), while the attitudes of patients were less positive (p ≤ 0.05). Residents underestimated faculty's (p < 0.001) and overestimated patients' HVCCC attitudes (p < 0.001). Increasing age was, among residents and faculty, associated with more positive attitudes toward HVCCC (p ≤ 0.05). Lower perceived health quality was associated with less positive attitudes among patients (p < 0.001). The more autonomy residents perceived, the more positive their HVCCC attitude (p ≤ 0.05). CONCLUSIONS Attitudes toward HVCCC vary among stakeholders in the residency learning environment, and residents misjudge the attitudes of both faculty and patients. Faculty and administrators might improve their support to residents by more explicitly sharing their thoughts and knowledge on HVCCC and granting residents autonomy in clinical practice.
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Affiliation(s)
- Serge B. R. Mordang
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | | | - Frank W. J. M. Smeenk
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Department of Pulmonary Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - Laurents P. S. Stassen
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karen D. Könings
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
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11
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Weng W, Van Parys J, Lipner RS, Skinner JS, Sirovich BE. Association of Regional Practice Environment Intensity and the Ability of Internists to Practice High-Value Care After Residency. JAMA Netw Open 2020; 3:e202494. [PMID: 32275322 PMCID: PMC7148442 DOI: 10.1001/jamanetworkopen.2020.2494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Use of health care services and physician practice patterns have been shown to vary widely across the United States. Although practice patterns-in particular, physicians' ability to provide high-quality, high-value care-develop during training, the association of a physician's regional practice environment with that ability is less well understood. OBJECTIVE To examine the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians whose practice environment changed due to relocation after residency. DESIGN, SETTING, AND PARTICIPANTS This cohort study included a national sample of 3896 internal medicine physicians who took the 2002 American Board of Internal Medicine initial certification examination followed approximately 1 decade (April 21, 2011, to May 7, 2015) later by the Maintenance of Certification (MOC) examination. At the time of the MOC examination, 2714 of these internists were practicing in a new region. Data were analyzed from March 6, 2016, to May 21, 2018. EXPOSURES Intensity of care in the Dartmouth Atlas hospital referral region (HRR), measured by per-enrollee end-of-life physician visits (primary) and current practice type (secondary). MAIN OUTCOMES AND MEASURES The outcome, a physician's ability to practice high-value care, was assessed using the Appropriately Conservative Management (ACM) score on the MOC examination, measuring performance across all questions for which the correct answer was the most conservative option. The exposure, regional health care intensity, was measured as per-enrollee end-of-life physician visits in the Dartmouth Atlas HRR of the physician's practice. RESULTS Among the 3860 participating internists included in the analysis (2030 men [52.6%]; mean [SD] age, 45.6 [4.5] years), those who moved to regions in the quintile of highest health care intensity had an ACM score 0.22 SD lower (95% CI, -0.32 to -0.12) than internists who moved to regions in the quintile of lowest intensity, controlling for postresidency ACM scores. This difference reflected scoring in the 44th compared with the 53rd percentile of all examinees. This association was mildly attenuated (0.18 SD less; 95% CI, -0.28 to -0.09) after adjustment for physician and practice characteristics. CONCLUSIONS AND RELEVANCE This study found that practice patterns of internists who relocate after residency training appear to migrate toward norms of the new region. The demands of practicing in high-intensity regions may erode the ability to practice high-value conservative care.
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Affiliation(s)
- Weifeng Weng
- American Board of Internal Medicine, Philadelphia, Pennsylvania
| | - Jessica Van Parys
- Department of Economics, Hunter College, New York, New York
- Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire
| | | | - Jonathan S. Skinner
- Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire
- Department of Economics, Dartmouth College, Hanover, New Hampshire
| | - Brenda E. Sirovich
- Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire
- Outcomes Group, Veterans Affairs Medical Center, White River Junction, Vermont
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12
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Leep Hunderfund AN, Starr SR, Dyrbye LN, Baxley EG, Gonzalo JD, Miller BM, George P, Morgan HK, Allen BL, Hoffman A, Fancher TL, Mandrekar J, Reed DA. Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity. J Gen Intern Med 2019; 34:1131-1138. [PMID: 30756307 PMCID: PMC6614293 DOI: 10.1007/s11606-019-04828-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 10/25/2018] [Accepted: 12/18/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns. OBJECTIVES To explore potential imprinting on clinical rotations by (a) describing high- and low-value behaviors among medical students and (b) examining relationships with regional healthcare intensity (HCI). DESIGN Multisite cross-sectional survey PARTICIPANTS: Third- and fourth-year students at nine US medical schools MAIN MEASURES: Survey items measured high-value (n = 10) and low-value (n = 9) student behaviors. Regional HCI was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data (ratio of physician visits per decedent compared with the US average, hospital care intensity index, ratio of medical specialty to primary care physician visits per decedent). Associations between regional HCI and student behaviors were examined using unadjusted and adjusted (controlling for age, sex, and year in school) logistic regression analyses, using median item ratings to summarize reported engagement in high- and low-value behaviors. KEY RESULTS Of 2623 students invited, 1304 (50%) responded. Many reported trying to determine healthcare costs (1085/1234, 88%), but only 45% (571/1257) reported including cost details in case presentations. Students acknowledged suggesting tests solely to anticipate what their supervisor would want (1143/1220, 94%), show off their ability to generate a broad differential diagnosis (1072/1218, 88%), satisfy curiosity (958/1217, 79%), protect the team from liability (938/1215, 77%), and build clinical experience (533/1217, 44%). Students in higher intensity regions reported significantly more low-value behaviors: each one-unit increase in the ratio of physician visits per decedent increased the odds of reporting low-value behaviors by 20% (OR 1.20, 95% CI 1.04-1.38; P = 0.01). CONCLUSIONS Third- and fourth-year medical students report engaging in both high- and low-value behaviors, which are related to regional HCI. This underscores the importance of the clinical learning environment and suggests imprinting is already underway during medical school.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Bradley L Allen
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ari Hoffman
- University of California, San Francisco, San Francisco, CA, USA
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Nordquist J, Hall J, Caverzagie K, Snell L, Chan MK, Thoma B, Razack S, Philibert I. The clinical learning environment. MEDICAL TEACHER 2019; 41:366-372. [PMID: 30880530 DOI: 10.1080/0142159x.2019.1566601] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative. The subject of the clinical learning environment (CLE) is at the forefront of discussions. In this introduction to a themed issue on the CLE, we present an expanded conceptual model that approaches the CLE through six different lenses, termed "avenues:" architectural, digital, diversity and inclusion, education, psychological, and sociocultural, with each avenue represented by a paper. The aim is to facilitate dialog around the contributions of different academic disciplines to research on the CLE. Collectively the papers highlight the overlap between the various "avenues" in how they influence each other, and how they collectively have shaped the work to understand and improve the CLE. The expectation is that the various avenues can add to existing knowledge and create new ideas for interventions to improve the clinical learning environment across nations for learners and teachers with the ultimate aim of improving patient care. Research and efforts to improve the CLE are critical to learning, professional socialization and well-being for trainees as they learn and participate in patient care, and to the quality of care they will deliver over decades of practice after graduation.
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Affiliation(s)
- Jonas Nordquist
- a Department of Medicine (Huddinge) , Karolinska Institutet , Stockholm , Sweden
- b Department of Research and Education , Karolinska University Hospital , Stockholm , Sweden
| | - Jena Hall
- c Department of Obstetrics and Gynecology , Queen's University , Kingston , Canada
| | - Kelly Caverzagie
- d Internal Medicine , University of Nebraska Medical Center , Omaha , NE , USA
| | - Linda Snell
- e Medicine , McGill University , Montreal , Canada
- f Royal College of Physicians and Surgeons of Canada , Ottawa , Canada
| | | | - Brent Thoma
- h University of Saskatchewan , Saskatoon , Canada
| | | | - Ingrid Philibert
- i Accreditation Council of Graduate Medical Education , Chicago , IL , USA
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Geleris JD, Shih G, Logio L. Analysis of Diagnostic Test Ordering Habits Among Internal Medicine Residents. JAMA Intern Med 2018; 178:1719-1721. [PMID: 30304333 PMCID: PMC6583600 DOI: 10.1001/jamainternmed.2018.3519] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study analyzes electronic diagnostic test ordering habits of internal medicine resident physicians at an academic medical center and during academic year 2016-2017.
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Affiliation(s)
- Joshua D Geleris
- Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, New York
| | - George Shih
- Department of Radiology, Weill Cornell Medical College, New York, New York
| | - Lia Logio
- Division of Internal Medicine, Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
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Ryskina K, Jessica Dine C, Gitelman Y, Leri D, Patel M, Kurtzman G, Lin LY, Epstein AJ. Effect of Social Comparison Feedback on Laboratory Test Ordering for Hospitalized Patients: A Randomized Controlled Trial. J Gen Intern Med 2018; 33:1639-1645. [PMID: 29790072 PMCID: PMC6153251 DOI: 10.1007/s11606-018-4482-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 02/14/2018] [Accepted: 05/04/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Social comparison feedback is an increasingly popular strategy that uses performance report cards to modify physician behavior. Our objective was to test the effect of such feedback on the ordering of routine laboratory tests for hospitalized patients, a practice considered overused. METHODS This was a single-blinded randomized controlled trial. Between January and June 2016, physicians on six general medicine teams at the Hospital of the University of Pennsylvania were cluster randomized with equal allocation to two arms: (1) those e-mailed a summary of their routine laboratory test ordering vs. the service average for the prior week, linked to a continuously updated personalized dashboard containing patient-level details, and snapshot of the dashboard and (2) those who did not receive the intervention. The primary outcome was the count of routine laboratory test orders placed by a physician per patient-day. We modeled the count of orders by each physician per patient-day after the intervention as a function of trial arm and the physician's order count before the intervention. The count outcome was modeled using negative binomial models with adjustment for clustering within teams. RESULTS One hundred and fourteen interns and residents participated. We did not observe a statistically significant difference in adjusted reduction in routine laboratory ordering between the intervention and control physicians (physicians in the intervention group ordered 0.14 fewer tests per patient-day than physicians in the control group, 95% CI - 0.56 to 0.27, p = 0.50). Physicians whose absolute ordering rate deviated from the peer rate by more than 1.0 laboratory test per patient-day reduced their laboratory ordering by 0.80 orders per patient-day (95% CI - 1.58 to - 0.02, p = 0.04). CONCLUSIONS Personalized social comparison feedback on routine laboratory ordering did not change targeted behavior among physicians, although there was a significant decrease in orders among participants who deviated more from the peer rate. TRIAL REGISTRATION Clinicaltrials.gov registration: #NCT02330289.
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Affiliation(s)
- Kira Ryskina
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - C Jessica Dine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Pulmonary and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yevgeniy Gitelman
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Damien Leri
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Mitesh Patel
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Gregory Kurtzman
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lisa Y Lin
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew J Epstein
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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Mirza A, Winer J, Garber M, Makker K, Maraqa N, Alissa R. Primer in Patient Safety Concepts: Simulation Case-Based Training for Pediatric Residents and Fellows. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2018; 14:10711. [PMID: 30800911 PMCID: PMC6342435 DOI: 10.15766/mep_2374-8265.10711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 04/05/2018] [Indexed: 05/29/2023]
Abstract
Introduction Health care quality and patient safety remain one of the core areas of focus for the Accreditation Council for Graduate Medical Education. In addition to using the traditional approach to teaching patient safety, disclosure of a safety event and introduction to the concepts of just culture and safely doing less add a unique perspective to our module. Methods This 4-hour learning activity was conducted using a formal PowerPoint presentation, simulation, and interactive discussion/debriefing. The presentation reviewed safety concepts and introduced learners to the concepts of just culture and safely doing less. The first case was a standard scenario in which participants assessed a sick but stable child and evaluated the use of premature closure bias that might preclude them from making the correct diagnosis. The second case represented disclosure of a medical error. Participants were evaluated on their communication/professionalism skills and challenged to discover overuse as one of the root causes of medication error. Pre- and posttest surveys were used for learner evaluation. Results Participants showed significant improvement on content-based questions, increasing from 51.7% to 69.3% correct (p < .001). After Bonferroni correction, only the question on overdiagnosis showed significant improvement (p = .001). Participants reported significantly increased confidence in all areas evaluated (p < .001). Discussion Participants placed high value on the workshop. The question on overdiagnosis showed significant improvement on the posttest. The concepts of patient safety, just culture, and safely doing less can be introduced to learners at a formative stage in their career through simulation.
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Affiliation(s)
- Ayesha Mirza
- Associate Professor, Department of Pediatrics, University of Florida College of Medicine
| | - Jeffrey Winer
- Assistant Professor, Department of Pediatrics, University of Florida College of Medicine
| | - Matthew Garber
- Professor, Department of Pediatrics, University of Florida College of Medicine
| | - Kartikeya Makker
- Assistant Professor, Department of Pediatrics, University of Florida College of Medicine
| | - Nizar Maraqa
- Associate Professor, Department of Pediatrics, University of Florida College of Medicine
| | - Rana Alissa
- Assistant Professor, Department of Pediatrics, University of Florida College of Medicine
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Phillips RL, Petterson SM, Bazemore AW, Wingrove P, Puffer JC. The Effects of Training Institution Practice Costs, Quality, and Other Characteristics on Future Practice. Ann Fam Med 2017; 15:140-148. [PMID: 28289113 PMCID: PMC5348231 DOI: 10.1370/afm.2044] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/17/2016] [Accepted: 11/25/2016] [Indexed: 01/17/2023] Open
Abstract
PURPOSE Medicare beneficiary spending patterns reflect those of the 306 Hospital Referral Regions where physicians train, but whether this holds true for smaller areas or for quality is uncertain. This study assesses whether cost and quality imprinting can be detected within the 3,436 Hospital Service Areas (HSAs), 82.4 percent of which have only 1 teaching hospital, and whether sponsoring institution characteristics are associated. METHODS We conducted a secondary, multi-level, multivariable analysis of 2011 Medicare claims and American Medical Association Masterfile data for a random, nationally representative sample of family physicians and general internists who completed residency between 1992 and 2010 and had more than 40 Medicare patients (3,075 physicians providing care to 503,109 beneficiaries). Practice and training locations were matched with Dartmouth Atlas HSAs and categorized into low-, average-, and high-cost spending groups. Practice and training HSAs were assessed for differences in 4 diabetes quality measures. Institutional characteristics included training volume and percentage of graduates in rural practice and primary care. RESULTS The unadjusted, annual, per-beneficiary spending difference between physicians trained in high- and low-cost HSAs was $1,644 (95% CI, $1,253-$2,034), and the difference remained significant after controlling for patient and physician characteristics. No significant relationship was found for diabetes quality measures. General internists were significantly more likely than family physicians to train in high-cost HSAs. Institutions with more graduates in rural practice and primary care produced lower-spending physicians. CONCLUSIONS The "imprint" of training spending patterns on physicians is strong and enduring, without discernible quality effects, and, along with identified institutional features, supports measures and policy options for improved graduate medical education outcomes.
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Affiliation(s)
| | | | | | | | - James C Puffer
- The American Board of Family Medicine, Inc, Lexington, KY
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Affiliation(s)
- Stephen Petterson
- Corresponding author: Stephen Petterson, PhD, Robert Graham Center, 1133 Connecticut Avenue, Suite 1100, Washington, DC 20036, 202.331.3360,
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