Knowledge and ideas to advance the field of academic medicine

Recent papers by OHSU School of Medicine faculty and staff in Academic Medicine grow body of knowledge

August 3, 2015

Over the last year, 14 OHSU School of Medicine faculty, trainees and staff have co-written new papers published in Academic Medicine, the journal serving as a global forum for academic medicine to advance knowledge and discuss issues facing the community.

These co-authors join OHSU colleagues and other academic health center peers as contributors to a global knowledge base for best practices in health care education. This educational research is an important aspect of fulfilling OHSU's mission of educating the next generation of scientists and health care professionals.

The papers often represent a multi-institutional scientific collaboration; the entire team may not be listed here.

Below are synopses in reverse chronological order. OHSU authors are noted in the following summaries; for full papers and complete author listings, please view the full papers provided below.

Have you or will you publish in Academic Medicine? Please abstracts.

AM aug 2015Transforming Primary Care Residency Training: A Collaborative Faculty Development Initiative Among Family Medicine, Internal Medicine, and Pediatric Residencies

OHSU co-authors: Patrice Eiff, M.D., professor of family medicine, and Patricia Carney, Ph.D., professor of family medicine

Publication date: August 2015

Synopsis: PROBLEM: The scope and scale of developments in health care redesign have not been sufficiently adopted in primary care residency programs.

APPROACH: The interdisciplinary Primary Care Faculty Development Initiative was created to teach faculty how to accelerate revisions in primary care residency training. The program focused on skill development in teamwork, change management, leadership, population management, clinical microsystems, and competency assessment. The 2013 pilot program involved 36 family medicine, internal medicine, and pediatric faculty members from 12 residencies in four locations.

OUTCOMES: The percentage of participants rating intention to implement what was learned as "very likely to" or "absolutely will" was 16/32 (50%) for leadership, 24/33 (72.7%) for change management, 23/33 (69.7%) for systems thinking, 25/32 (75.8%) for population management, 28/33 (84.9%) for teamwork, 29/33 (87.8%) for competency assessment, and 30/31 (96.7%) for patient centeredness.Content analysis revealed five key themes: leadership skills are key drivers of change, but program faculty face big challenges in changing culture and engaging stakeholders; access to data from electronic health records for population management is a universal challenge; readiness to change varies among the three disciplines and among residencies within each discipline; focusing on patients and their needs galvanizes collaborative efforts across disciplines and within residencies; and collaboration among disciplines to develop and use shared measures of residency programs and learner outcomes can guide and inspire program changes and urgently needed educational research.

NEXT STEPS: Revise and reevaluate this rapidly evolving program toward widespread engagement with family medicine, internal medicine, and pediatric residencies

Read more: Find additional details in this PDF of the full paper.

AM aug 2015Learn, see, practice, prove, do, maintain: An evidence-based pedagogical framework for procedural skill training in medicine

OHSU co-author:  JoDee Anderson, M.D., MEd, associate professor of pediatrics

Publication date: August 2015

Synopsis: Acquisition of competency in procedural skills is a fundamental goal of medical training. In this Perspective, the authors propose an evidence-based pedagogical framework for procedural skill training. The framework was developed based on a review of the literature using a critical synthesis approach and builds on earlier models of procedural skill training in medicine.

The authors begin by describing the fundamentals of procedural skill development. Then, a six-step pedagogical framework for procedural skills training is presented: Learn, See, Practice, Prove, Do, and Maintain. In this framework, procedural skill training begins with the learner acquiring requisite cognitive knowledge through didactic education (Learn) and observation of the procedure (See). The learner then progresses to the stage of psychomotor skill acquisition and is allowed to deliberately practice the procedure on a simulator (Practice). Simulation-based mastery learning is employed to allow the trainee to prove competency prior to performing the procedure on a patient (Prove). Once competency is demonstrated on a simulator, the trainee is allowed to perform the procedure on patients with direct supervision, until he or she can be entrusted to perform the procedure independently (Do). Maintenance of the skill is ensured through continued clinical practice, supplemented by simulation-based training as needed (Maintain).

Evidence in support of each component of the framework is presented. Implementation of the proposed framework presents a paradigm shift in procedural skill training. However, the authors believe that adoption of the framework will improve procedural skill training and patient safety.”

Read more: Find additional details in this PDF of the full paper.

AM april 2015The development of entrustable professional activities for internal medicine residency training: A report from the education redesign committee of the alliance for academic internal medicine

OHSU co-author:  Thomas Cooney, M.D., professor of medicine

Publication date: April 2015

Synopsis: PURPOSE: The Alliance for Academic Internal Medicine charged its Education Redesign Committee with the task of assisting internal medicine residency program directors in meeting the challenges of competency-based assessment that were part of the Accreditation Council for Graduate Medical Education's (ACGME's) Next Accreditation System.

METHOD: Recognizing the limitations of the ACGME general competencies as an organizing framework for assessment and the inability of the milestones to provide the needed context for faculty to assess residents' competence, the Education Redesign Committee in 2011 adopted the work-based assessment framework of entrustable professional activities (EPAs). The committee selected the EPA framework after reviewing the literature on competency-based education and EPAs and consulting with experts in evaluation and assessment. The committee used an iterative approach with broad-based feedback from multiple sources, including program directors, training institutions, medical organizations, and specialty societies, to develop a set of EPAs that together define the core of the internal medicine profession.

RESULTS: The resulting 16 EPAs are those activities expected of a resident who is ready to enter unsupervised practice, and they provide a starting point from which training programs could develop assessments and curricula. The committee also provided a strategy for the use of these EPAs in competency-based evaluation.

CONCLUSIONS: These EPAs are intended to serve as a starting point or guide for program directors to begin developing meaningful, work-based assessments that inform the evaluation of residents' competence.

Read more: Find additional details in this OvidSP link to the full paper.

AM april 2015Using self-determination theory to improve residency training: Learning to make omelets without breaking eggs

OHSU author: Benjamin Hoffman, M.D., professor of pediatrics

Publication date: April 2015

Synopsis: As health care reform continues, health care organizations are evolving both structurally and operationally to position themselves to meet the challenges ahead. Academic medical centers (i.e., teaching hospitals) particularly need an effective strategy that will allow them to meet their tripartite missions of patient care, education, and research in this time of increasing competition and resource constraints.

Clarian Health Partners, recently renamed Indiana University Health, is a health care entity that developed from a partnership of the Indiana University Hospitals and Methodist Hospital of Indiana. This case study explores the history behind the development of Clarian Health Partners, the model employed, and the lessons learned. It discusses the governance and management models implemented, the steps taken to integrate the two partners in the new system, and the specific challenges of physician partnerships and collaborations. As mergers and consolidations continue in an era of health care reform, the lessons learned from previous endeavors, such as that of Clarian Health Partners, may be applicable.

Read more: Find additional details in this OvidSP link to the full paper.

AM feb 2015Integrating basic science without integrating basic scientists: Reconsidering the place of individual teachers in curriculum reform

OHSU co-author:  Judith Bowen, M.D., professor of medicine

Publication date: February 2015

Synopsis: The call for integration of the basic and clinical sciences plays prominently in recent conversations about curricular change in medical education; however, history shows that, like other concepts related to curricular reform, integration has been continually revisited, leading to incremental change but no meaningful transformation.

To redress this cycle of "change without difference," the medical education community must reexamine the approach that dominates medical education reform efforts and explore alternative perspectives that may help to resolve the cyclical "problem" of recommending but not effecting integration. To provide a different perspective on implementing integration, the authors of this Perspective look to the domain of educational change as an approach to examining the transitions that occur within complex and evolving environments.

This area of literature both acknowledges the multiple levels involved in change and emphasizes the need not only to address systemic structure but also to prioritize individuals during times of transition. The struggle to implement curricular integration in medical education may stem from the fact that reform efforts appear to focus largely on transformation at the level of curricular structure as opposed to considering what learning needs to occur at each level of change and highlighting the individual as the educational change literature suggests. To bring appropriate attention to the place of individual educators, especially basic scientists, the medical education community should explore how the mandate to integrate clinically relevant material may impact these faculty and the teaching of their domains.”

Read more: Find additional details in this OvidSP link to the full paper.

AM dec 2014Advancing educational continuity in primary care residencies: An opportunity for patient-centered medical homes

OHSU co-authors: Judith Bowen, M.D., professor of medicine, Joseph Hardman, M.D., assistant professor or medicine

Publication date: December 2014

Synopsis: Continuity of care is a core value of patients and primary care physicians, yet in graduate medical education (GME), creating effective clinical teaching environments that emphasize continuity poses challenges. In this Perspective, the authors review three dimensions of continuity for patient care-informational, longitudinal, and interpersonal-and propose analogous dimensions describing continuity for learning that address both residents learning from patient care and supervisors and interprofessional team members supporting residents' competency development.

The authors review primary care GME reform efforts through the lens of continuity, including the growing body of evidence that highlights the importance of longitudinal continuity between learners and supervisors for making competency judgments. The authors consider the challenges that primary care residency programs face in the wake of practice transformation to patient-centered medical home models and make recommendations to maximize the opportunity that these practice models provide. First, educators, researchers, and policy makers must be more precise with terms describing various dimensions of continuity. Second, research should prioritize developing assessments that enable the study of the impact of interpersonal continuity on clinical outcomes for patients and learning outcomes for residents. Third, residency programs should establish program structures that provide informational and longitudinal continuity to enable the development of interpersonal continuity for care and learning. Fourth, these educational models and continuity assessments should extend to the level of the interprofessional team. Fifth, policy leaders should develop a meaningful recognition process that rewards academic practices for training the primary care workforce.

Read more: Find additional details in this OvidSP link to the full paper.

AM oct 2014Promoting resident wellness: Evaluation of a time-off policy to increase residents' utilization of health care services

OHSU co-authors: Andrea Cedfeldt, M.D., associate professor of medicine; Elizabeth Bower, M.D., MPH, associate professor of medicine; Christine Flores, division of graduate medical education, Patrick Brunett, M.D., FACEP, associate dean for graduate medical education, Dongseok Choi, Ph.D., associate professor, Department of Public Health and Preventive Medicine, Donald Girard, M.D., MACP, professor of medicine.

Publication date: October 2014

Synopsis: PURPOSE: To evaluate awareness and utilization of a new institutional policy to grant residents time off to access personal and family health care.

METHOD: In 2012, two years after policy implementation, an electronic survey was sent to all 546 residents and fellows at a tertiary care academic medical center in the United States. Residents were asked questions regarding awareness of the time-off policy, use of the policy, health care status, reasons for policy use, and barriers to use.

RESULTS: A total of 490 (90%) residents responded. Eighty-nine percent of those surveyed were aware of the policy. Of those who were aware, 49.7% used the policy to access health care. Top reasons for policy use were for personal routine or preventive health care, dental care, and urgent health care needs. The most commonly reported barrier to policy use was concern about the impact the resident's absence would have on colleagues.

CONCLUSIONS: Implementation of policies to prospectively schedule residents' time off during business hours to address health care needs is an important means to promote resident wellness. Such policies remove one commonly cited barrier to residents' access to health care. However, residents still reported concerns about impact on peers and patients as the main reason they were reluctant to take the time off to address their health care needs. More work is needed on both wellness policy implementation practices and on refining the systems that will allow seamless and guiltless transitions of care.

Read more: Find additional details in this OvidSP link to the full paper.

AM oct 2014Medical interpreters: Improvements to address access, equity, and quality of care for limited-english-proficient patients

OHSU co-author:  David R. Nagarkatti-Gude, M.D., Ph.D., psychiatry resident

Publication date:  October 2014

Synopsis: Limited-English-proficient (LEP) patients in the United States experience a variety of health care disparities associated with language barriers, including reduced clinical encounter time and substandard medical treatment compared with their English-speaking counterparts. In most current U.S. health care settings, interpretation services are provided by personnel ranging from employed professional interpreters to untrained, ad hoc interpreters such as friends, family, or medical staff. Studies have demonstrated that untrained individuals commit many interpretation errors that may critically compromise patient safety and ultimately prove to be life-threatening. Despite documented risks, the U.S. health care system lacks a required standardized certification for medical interpreters.

The authors propose that the standardization of medical interpreter training and certification would substantially reduce the barriers to equitable care experienced by LEP patients in the U.S. health care system, including the occurrence of preventable clinical errors. Recent efforts of the U.S. federal court system are cited as a successful and realistic example of how these goals may be achieved. As guided by the evolution of the federal court interpreting certification program, subsequent research will be required to demonstrate the improvements and challenges that would result from national certification standards and policy for medical interpreters. Research should examine cost-effectiveness and ensure that certified interpreting services are appropriately used by health care practitioners. Ongoing commitment is required from lawmakers, health care providers, and researchers to remove barriers to care and to demand that equity remain a consistent goal of our health care system.

Read more: Find additional details in this OvidSP link to the full paper.