Computerised provider order entry and residency education in an academic medical centre

Medical Education 2012: 46: 795–806 Context Many academic medical centres (AMCs) have introduced institutional policies, changed processes of care and implemented new technologies to improve health care quality. The impact of such changes on medical education has received little attention. We examine the impact of computerised provider order entry (CPOE) on the educational experiences of medical trainees who work and train in AMCs. Methods We conducted semi‐structured interviews of postgraduate trainees and attending physicians in internal medicine at five AMCs (two with CPOE, three without CPOE). Trainees routinely rotate from CPOE to non‐CPOE AMCs, whereas some attending physicians work at both types of AMC and are therefore well positioned to reflect on differences between CPOE and non‐CPOE learning environments. Data collection and analysis used grounded theory methods. We sampled purposively until we achieved theoretical saturation. Results Our study included 11 residents and six attending physicians. Computerised provider order entry had both positive and negative impacts on five aspects of postgraduate training: (i) learning (better for medication interactions and availability of learning resources; worse for learning medication doses); (ii) teaching (more medication information available to enhance case discussions; fewer face‐to‐face teaching opportunities); (iii) feedback (improved ability to observe medication ordering behaviours to inform feedback; less provision of direct feedback); (iv) clinical supervision (facilitates efficient and safe supervision from a distance; may impede trainee independence), and (v) trainee assessment (increased opportunity to assess clinical decision‐making and organisational skills). Conclusions We identify five key educational themes that are positively and negatively impacted by CPOE. These themes form a conceptual framework that could be applied to define the educational impact of other health care quality and patient safety practices. This will help educators to identify educational opportunities and protect the safety of the training experience of residents in AMCs.     

Learning to doctor: tinkering with visibility in residency training

Medical doctors in teaching hospitals aim to serve the two central goals of patient care and medical training. Whereas patient care asks for experience, expertise and close supervision, medical training requires space to practise and the ‘invisibility’ of medical residents. Yet current reforms in postgraduate medical training point to an increasing emphasis on the measurable visibility of residents. Drawing on an ethnographic study of gynaecology training in The Netherlands, this article demonstrates that in daily clinical routines multiple practices of residents’ visibility (visibilities) coexist. The article lists four visibilities: staging residents, negotiating supervision, playing the invisibility game and filming surgical operations. The article shows how attending physicians and medical residents tinker with these visibilities in daily clinical work to provide good care while enacting learning space, highlighting the increasing importance of visualising technologies in clinical work. Moreover, the article contributes to traditional sociological accounts on medical education, shifting the focus from medical education as a social institution to the practices of medical training itself. Such a focus on practice helps to gain an understanding of how the current reform challenges clinicians’ educational activities.     

Attending doctors' perspectives on how residents learn

CONTEXT: Graduate medical education is currently facing major educational reforms. There is a lack of empirical evidence in the literature about the learning processes of residents in the clinical workplace. This qualitative study uses a 'grounded theory' approach to continue the development of a theoretical framework of learning in the clinical workplace by adding the perspective of attending doctors. METHODS: A total of 21 Dutch attending doctors involved in the training of residents in obstetrics and gynaecology participated in 1 of 3 focus group sessions. They discussed their perceptions of how residents learn and what factors influence residents' learning. A grounded theory approach was used to analyse the transcribed discussions. RESULTS: Three related themes emerged. The first concerned the central role of participation in work-related activities: according to attending doctors, residents learn by tackling the everyday challenges of clinical work. The second involved the ways in which attending doctors influence what residents learn from work-related activities. The final theme focused on attending doctors' views of the essential characteristics of residents and their development during residency. CONCLUSIONS: Attending doctors' perspectives complement current insights derived from similar research among residents and from related literature. As part of an ongoing effort to further develop understanding of how residents learn, this study adds several ways in which attending doctors strive to combine guidance in both patient care and resident training. Furthermore, attending doctors' perspectives draw attention to other aspects of learning in the clinical workplace, such as the role of confidence and the balance between supervision and independence.     

The physician as teacher. Ways to measure the quality of medical training

Ninety percent of medical students' training is comprised of working and learning in the clinical setting. Good training is the responsibility of the physicians who also work in that setting. It is important that these physicians are aware of what is expected of them in this role. We defined 7 domains for clinical teachers: being a role model, task allocation, planning, providing feedback, teaching methodology, assessment, and personality. There are several feedback instruments for measuring the quality of a clinical teacher, each addressing these seven domains differently. When providing clinical teachers with feedback, written evaluation alone is not sufficient to induce change. Dialogue between residents and their clinical teacher leads to mutual understanding and enhances the effect of feedback. This is beneficial to the individual trainer, training team and the residents.     

Development of a curriculum in colposcopy

BACKGROUND. Colposcopy for the detection of genital malignancy and disease associated with human papillomavirus, along with cytologic screening and histopathologic correlation, allows for intervention before the onset of invasive disease. Family physicians are interested in learning colposcopy, but there are few reports in the literature on the training of colposcopists. METHODS. A colposcopy curriculum for family physicians was designed with goals, objectives, and instructional strategies selected to enhance learning and quality assurance of the current principles of colposcopic evaluation. During the pilot project, a third-year resident studied a syllabus and reviewed slides, practiced performance skills, and observed colposcopies. After demonstrating competence, the resident evaluated patients with instructor supervision and feedback. RESULTS. Resident performance data from written test scores and a performance checklist indicated an excellent learning curve. High resident satisfaction was reported. Suggestions from expert reviewers were incorporated into the final curriculum product. The evaluation data indicated that, based on this pilot program, family practice residents can effectively learn colposcopy. CONCLUSIONS. Colposcopy is a highly technical skill that can be learned by family physicians through professional training. Competency in colposcopy can provide a new dimension to their practice in the diagnosis and treatment of female lower-genital-tract disease. This colposcopy curriculum is an initial effort in the identification of the content and process required to train family physicians in the use of this diagnostic procedure.     

A survey of Massachusetts physicians' smoking intervention practices

Attitudes toward smoking intervention, and the intervention practices of 65 residents, 51 attending physicians, and 292 community physicians in central and western Massachusetts were assessed through a mailed questionnaire. Nearly all physicians reported that they obtained information on the smoking status of new patients and told smokers to quit. Proportionately fewer physicians, however, reported that they counseled their patients on how to stop smoking; those who did, did so for relatively brief periods of time. After differences in physician age and smoking status were controlled for, residents were significantly more likely than attending physicians to counsel their patients on how to stop smoking, but were also more likely (than attending and community physicians) to recommend or refer their patients to formal smoking cessation programs. A small percentage of the physicians responding (3%-16%) reported that they were prepared to counsel smokers, but most reported that information on where to refer patients, smoking cessation techniques, and skills training would be of great value. The results of this survey suggest practical differences between residents and attending and community physicians in approaching patients who smoke and in attitudes toward the need for additional skills and financial and organizational assistance.     

Use of critical incidents to develop a rating form for resident evaluation of faculty teaching

CONTEXT: Monitoring the teaching effectiveness of attending physicians is important to enhancing the quality of graduate medical education. METHODS: We used a critical incident technique with 35 residents representing a cross-section of programmes in a teaching hospital to develop a 23-item rating form. We obtained ratings of 11 attending physicians in internal medicine and general surgery from 54 residents. We performed linear and logistic regression analysis to relate the items on the form to the residents' overall ratings of the attending physicians and the programme directors' ratings of the attending physicians. RESULTS: The residents rated the attending physicians highly in most areas, but lower in provision of feedback, clarity of written communication and cost-effectiveness in making clinical decisions. When we used the residents' overall ratings as the criterion, the most important aspects of attending physicians' teaching were clarity of written communication, cost-effectiveness, commitment of time and energy and whether the resident would refer a family member or friend to the physician. When we used the programme directors' ratings as the criterion, the additional important aspects of performance were concern for the residents' professional well-being, knowledge of the literature and the delivery of clear verbal and written communication. CONCLUSIONS: The critical incident technique can be used to develop an instrument that demonstrates content and construct validity. We found that residents consider commitment of time to teaching and clinical effectiveness to be the most important dimensions of faculty teaching. Other important dimensions include written and verbal communication, cost-effectiveness and concern for residents' professional development.     

Meeting the needs of future physicians: a core curriculum initiative for postgraduate medical education at a Canadian university

In addition to possessing medical expertise, contemporary physicians are expected to be skilled communicators, critical consumers and users of medical research, teachers, collaborators, health care advocates, and managers. A core curriculum is a common set of learning experiences designed to help prepare physicians for these complex roles. PURPOSE: This article describes the design and implementation of one core curriculum, summarizes the feedback received from residents, and shares some of the lessons we are learning as we use feedback to develop our programme. METHOD: The core curriculum described was implemented at a Canadian university which offers 56 residency programmes with a total enrollment of approximately 360 students. The curriculum consisted of 30 sessions organized around four themes: biostatistics and epidemiology; communications and teaching skills; healthcare management, and ethical, medicolegal and lifestyle issues. Each session in the Core Curriculum was evaluated by residents with respect to the timing, quality, and value of the learning experience. In addition, residents participated in focus group discussions of their Core Curriculum experiences. RESULTS: Key findings related to the characteristics of effective core curriculum learning experiences and to the barriers to implementing a core curriculum across programmes. Of particular salience were findings related to explicit issues of attendance and the diverse needs of learners and programmes, and to more implicit issues of communication and managing change. The specific content and format of the Core Curriculum and the results of the evaluation process will be of interest to others considering a core curriculum for postgraduate medical programmes.     

Patterns of direct observation and their impact during residency: general practice supervisors’ views

Context

Direct observation (DO) of residents’ performance, despite the importance that is ascribed to it, does not readily fit in with the practice of postgraduate medical education (PGME); it is infrequent and the quality of observation may be poor in spite of ongoing efforts towards improvement. In recent literature, DO is mostly portrayed as a means to gather information on the performance of residents for purposes of feedback and assessment. The role of DO in PGME is likely to be more complex and poorly understood in the era of outcome‐based education. By exploring the possible complexity of DO in workplace learning, our research aims to contribute to a better use of DO in the practice of PGME.

Methods

Constructivist grounded theory informed our data collection and analysis. Data collection involved focus group sessions with supervisors in Dutch general practice who were invited to discuss the manifestations, meanings and effects of DO of technical skills. Theoretical sufficiency was achieved after four focus groups, with a total of 28 participants being included.

Results

We found four patterns of DO of technical skills: initial planned DO sessions; resident‐initiated ad hoc DO; supervisor‐initiated ad hoc DO, and continued planned DO sessions. Different patterns of DO related to varying meanings, such as checking or trusting, and effects, such as learning a new skill or experiencing emotional discomfort, all of them concerning the training relationship, patient safety or residents’ learning.

Conclusions

Direct observation, to supervisors, means much more than gathering information for purposes of feedback and assessment. Planned DO sessions are an important routine during the initiation phase of a training relationship. Continued planned bidirectional DO sessions, although infrequently practised, potentially combine most benefits with least side‐effects of DO. Ad hoc DO, although much relied upon, is often hampered by internal tensions in supervisors, residents or both.     

Comparison of dermatologic diagnoses by primary care practitioners and dermatologists. A review of the literature

BACKGROUND: Cost-containment efforts in the United States have led to a greater emphasis on health care delivery by primary care physicians as opposed to specialists, who are assumed to be more costly. With this approach, it is incumbent on the primary care physician to be able to accurately diagnose and treat common maladies, including skin disease. OBJECTIVE: To ascertain whether differences in performance were detectable between groups of physicians when presented with color slides or high-quality transparencies. DESIGN: We performed a critical review of published studies. RESULTS: Overall, dermatologists (93% correct) performed better than nondermatologists (52% correct) (P < .001). No difference was appreciable between dermatology residents (91% correct) and practicing dermatologists (96% correct) or between internal medicine residents (45% correct) and family practice residents (48% correct). In addition, family medicine attending physicians (70% correct) performed better than internal medicine attending physicians (52% correct) (P < .001). CONCLUSION: Primary care physicians should receive more training in the diagnosis of skin disease.     

The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students

INTRODUCTION: Much of undergraduate clinical teaching is provided by residents. An earlier study showed the attitude of residents towards teaching to be generally positive. Little is known, however, about attending doctors' views on their own and residents' roles as teachers of medical students. OBJECTIVES: To examine attending doctors' perceptions of the (dis)advantages of resident teaching, their own teaching abilities and the need for a teacher training programme for residents. METHOD: A questionnaire survey of 76 attending doctors was carried out in the Departments of Obstetrics & Gynaecology and Paediatrics at the teaching hospitals of the Universities of Maastricht and Amsterdam, the Netherlands. RESULTS: Attending doctors perceive teaching by residents to be beneficial for students and residents alike. Although they consider themselves to be better suited than residents to teach medical students, they see teaching as an integral part of residency training and feel it should be recognised as such by departments and medical schools. Attending doctors are in favour of a teacher training programme for residents, which should include communication, clinical and teaching skills as well as skills such as time management and (self-) assessment. DISCUSSION: Despite the uneven distribution of participants between the departments, no significant differences were found between departments. It is interesting that attending doctors perceive teacher training as beneficial to residents' teaching skills, but provide more feedback on residents' attitudes than on their teaching. The results show that, in general, attending doctors share residents' views that teaching is an important component of residency and that a teacher training programme for residents is to be recommended.     

Resigned professionalism? Non-acute inpatients and resident education

A growing group of inpatients on acute clinical teaching units have non-acute needs, yet require attention by the team. While anecdotally, these patients have inspired frustration and resource pressures in clinical settings, little is known about the ways in which they influence physician perceptions of the learning environment. This qualitative study explored residents’ and attending physicians’ perceptions of caring for these patients, including their educational value. Using constructivist grounded theory, we conducted seven homogeneous focus groups and three interviews with residents and attending physicians from neurology and general internal medicine. A constant comparative analytical approach was employed alongside data collection, using theoretical sampling to explore emergent themes. Residents consistently described non-acute patients as non-educational, uninteresting, but still in need of care. Some attending physicians echoed this view, while others described multiple learning opportunities presented by non-acute patients. Both groups described residents as engaging with non-acute patients in a professional capacity, but not as learners. This engagement in a professional capacity could be considered diligent disinterest, or resigned professionalism. A constructivist understanding of the dynamics which influence learning in the workplace was used to explore the reasons why the residents in our study did not recognize the learning opportunities presented by non-acute patients. Our results resonate with Billett’s theory of workplace affordances, which offers an explanation as to why learners may not identify or take advantage of potential learning opportunities. Overall, our study assists our understanding of the sociocultural factors that influence learners’ choices to engage with particular clinical learning opportunities.     

The effects of nutrition education on professionals' practice and on the nutrition of aged residents in dementia wards

OBJECTIVE: (1) To develop nutrition education for professionals in dementia wards. (2) To evaluate the effects of education and determine the outcome of the education on the nutrition of aged residents. DESIGN: Educational intervention with before and after measurements. Both the learning outcomes of the professionals and the effect on the aged residents were assessed. SETTING: Nursing home residents in dementia wards and professionals. SUBJECTS AND METHODS: Twenty-eight professionals completed half-structured feedback questionnaires that were analysed quantitatively and qualitatively. Assessments of 21 residents' energy and nutrient intake and 19 residents' nutritional status with the MNA before and after the education. RESULTS: The learning process included six half-day training sessions. The professionals learned to use and interpret the MNA and detailed food diaries. Keeping the food diaries and analysing them in multi-professional teams was experienced as the main source for learning insights. After calculating the diets and discussing with others, professionals felt easier about responding to the nutritional problems of the residents. After 1 year, the residents' mean energy intake had increased 21% from 1230 to 1487 kcal. Before the education none but after 1 year 16% had a good nutritional status according to the MNA. CONCLUSIONS: We used the constructive learning theory to educate professionals. Keeping and analysing food diaries and reflecting on nutritional issues in small group discussions were effective training methods for professionals. The education had positive effects on the nutrition of the residents in dementia wards.     

Nutrition support in the critically ill: a physician survey

Background: Current clinical practice guidelines delineate optimal nutrition management in the intensive care unit (ICU) patient. In light of these existing data, the authors identify current physician perceptions of nutrition in critical illness, preferences relating to initiation of feeding, and management practices specific to nutrition after initiation of feeding in the ICU patient. Methods: The authors electronically distributed a 12‐question survey to attending physicians, fellows, and residents who routinely admit patients to medical and surgical ICUs. Results: On a scale ranging from 1 to 5 (1 = low, 5 = high), the attending physician's mean rating for importance of nutrition in the ICU was 4.60, the rating for comfort level with the nutrition support at the authors' institution was 3.70, and the rating for the physician's own understanding of nutrition support in critically ill patients was 3.33. Attending physicians, fellows, and residents reported waiting an average of 2.43, 1.79, and 2.63 days, respectively, before addressing nutrition status in an ICU patient. Fifty‐two percent of attending physicians chose parenteral nutrition as the preferred route of nutrition support in a patient with necrotizing pancreatitis. If a patient experiences enteral feeding intolerance, physicians most commonly would stop tube feeds. There was no significant difference in responses to any of the survey questions between attending physicians, fellows, and residents. Conclusions: This study demonstrates a substantial discordance in physician perceptions and practice patterns regarding initiation and management of nutrition in ICU patients, indicating an urgent need for nutrition‐related education at all levels of training.     

Exploring deliberate practice in medicine: how do physicians learn in the workplace?

Medical professionals need to keep on learning as part of their everyday work to deliver high-quality health care. Although the importance of physicians’ learning is widely recognized, few studies have investigated how they learn in the workplace. Based on insights from deliberate practice research, this study examined the activities physicians engage in during their work that might further their professional development. As deliberate practice requires a focused effort to improve performance, the study also examined the goals underlying this behaviour. Semi-structured interviews were conducted with 50 internal medicine physicians: 19 residents, 18 internists working at a university hospital, and 13 working at a non-university hospital. The results showed that learning in medical practice was very much embedded in clinical work. Most relevant learning activities were directly related to patient care rather than motivated by competence improvement goals. Advice and feedback were sought when necessary to provide this care. Performance standards were tied to patients’ conditions. The patients encountered and the discussions with colleagues about patients were valued most for professional development, while teaching and updating activities were also valued in this respect. In conclusion, physicians’ learning is largely guided by practical experience rather than deliberately sought. When professionals interact in diagnosing and treating patients to achieve high-quality care, their experiences contribute to expertise development. However, much could be gained from managing learning opportunities more explicitly. We offer suggestions for increasing the focus on learning in medical practice and further research.     

Improving the quality of nurse assistants in nursing homes: report of an attending physician survey and an AMDA Symposium

OBJECTIVES: To describe views of attending physicians regarding nurse assistants as part of a multidisciplinary seminar on nurse assistants at the 1997 American Medical Directors Association (AMDA) Annual Symposium. DESIGN: Mailed survey. PARTICIPANTS: AMDA members. MEASUREMENTS: Attitudes regarding nurse assistants and the role of attending physicians with regard to enhancing the role of nurse assistants. RESULTS: Respondents rated the importance of quality nurse assistants with a mean of 4.85 and a mode of 5 (5 being very important). They also thought it was important for the medical director attending physicians to support, train, or otherwise assist in the professional development of nurse assistants (mean 4.07, mode 5). Respondents recommended enhanced training, reduced workload, increased salary and benefits, and building more effective relationships as strategies for improving the quality of care provided by nurse assistants. CONCLUSION: Physicians can be important in enhancing the role of the nursing assistant. Some activities may include acknowledging the nurse assistant, providing support and feedback, and supporting policy changes that enhance continuity, nonhierarchical management, and creative training programs.     

Using optimization models to demonstrate the need for structural changes in training programs for surgical medical residents

The primary goal of a residency program is to prepare trainees for unsupervised care. Duty hour restrictions imposed throughout the prior decade require that residents work significantly fewer hours. Moreover, various stakeholders (e.g. the hospital, mentors, other residents, educators, and patients) require them to prioritize very different activities, often conflicting with their learning goals. Surgical residents’ learning goals include providing continuity throughout a patient’s pre-, peri-, and post-operative care as well as achieving sufficient surgical experience levels in various procedure types and participating in various formal educational activities, among other things. To complicate matters, senior residents often compete with other residents for surgical experience. This paper features experiments using an optimization model and a real dataset. The experiments test the viability of achieving the above goals at a major academic center using existing models of delivering medical education and training to surgical residents. It develops a detailed multi-objective, two-stage stochastic optimization model with anticipatory capabilities solved over a rolling time horizon. A novel feature of the models is the incorporation of learning curve theory in the objection function. Using a deterministic version of the model, we identify bounds on the achievement of learning goals under existing training paradigms. The computational results highlight the structural problems in the current surgical resident educational system. These results further corroborate earlier findings and suggest an educational system redesign is necessary for surgical medical residents.     

How medical residents perceive the quality of supervision provided by attending doctors in the clinical setting

INTRODUCTION: The supervision of medical residents is a key responsibility of attending doctors in the clinical setting. Most attending doctors, however, are unfamiliar with the principles of effective supervision. Although inconsistent, supervision has been shown to be both important and effective for the professional development of medical residents. OBJECTIVE: To examine how medical residents perceive the supervisory roles of attending doctors, in terms of what they perceive as poor supervision and what they characterise as good supervisory practice. METHOD: We carried out a questionnaire survey of 38 medical residents at the Department of Paediatrics at the teaching hospital of the University of Amsterdam, the Netherlands. Attending doctors directly involved with the supervision of medical residents participated in the study. The clinical settings where supervision occurred included the neonatal and paediatric intensive care units and the general paediatric wards. RESULTS: Medical residents rated the quality of supervision they received in all departments positively. A majority of the attending doctors were rated highly in 'overall supervision'. Creating pleasant learning environments and being stimulated to learn and function independently were aspects of supervision characterised positively. Coaching in clinical skills and procedures, effective communication skills and clinical decision making using principles of cost-appropriate care were aspects of supervision found to be deficient. DISCUSSION: This study shows that medical residents enjoy supervision from collaborative, understanding and patient attending doctors. Medical residents prefer to be treated as adult learners and enjoy feedback that is constructive, measured and adapted to their professional needs.     

Examiner Differences in the Mini-Cex

Objective: The objective of this study was to analyze whether faculty ratings of residents, using the mini-CEX oral exam format, differed in stringency or were influenced by the clinical setting. It also sought to learn whether the examiners were satisfied with the format.Method: A mini-CEX encounter consisted of a single faculty member observing a resident conduct a focused history and physical examination in an inpatient, outpatient, or emergency room setting. After asking the resident for a diagnosis and treatment plan, the faculty member rated the resident and provided educational feedback. The encounters were intended to be short and occur as a routine part of the training, so each resident would be evaluated on many occasions by different faculty.Sample: Sixty-four attending physicians evaluated residents from five internal medicine training programs; data were analyzed for 355 mini-CEX encounters involving 88 residents.Results: There were not large differences among the examiners in their ratings. Moreover, there were not great differences among the ratings in terms of the training program with which the examiner was associated, the setting of the mini-CEX, or the nature of the patient. The examiners were generally satisfied with the format and their level of satisfaction was correlated with the residents' perceptions of the format.Conclusion: The mini-CEX adapts itself to a broad range of clinical situations, and these results show that it should produce roughly comparable scores over examiners and settings. This makes it a worthwhile device for evaluation at the local level.This revised version was published online in September 2005 with corrections to the Cover Date.     

Social workers’ perceptions of barriers to interpersonal therapy implementation for treating postpartum depression in a primary care setting in Israel

Research on evidence‐based practice (EBP) implementation in social work often neglects to include evaluation of application barriers. This qualitative study examined social workers’ perspectives of provider‐ and organisational‐related barriers to implementing a brief eight‐session interpersonal therapy (IPT) intervention, a time‐limited EBP that addresses reducing depressive symptoms and improving interpersonal functioning. Implementation took place in a primary care setting in Israel and was aimed at treating women who have postpartum depression (PPD) symptoms. Using purposeful sampling, 25 primary care licensed social workers were interviewed between IPT training and implementation regarding their perceived barriers to implementing IPT in practice. Data analysis was facilitated using a phenomenological approach, which entails identifying the shared themes and shared experiences of research participants regarding barriers to implementing IPT. Three themes emerged from the analysis of interviews: Perceived lack of flexibility of IPT intervention in comparison with more familiar methods social workers previously applied, specifically regarding the number of sessions and therapeutic topics included in the IPT protocol; insecurity and hesitance to gain experience with a new method of intervention; and organisational barriers, including difficulties with referrals, the perception of HMOs as health facilities not suitable for therapy, and time constraints. Addressing perceived barriers of social workers toward implementing EBPs, such as IPT for postpartum depression, during the training phase is crucial for enabling appropriate implementation. Future training should include examining practitioners’ attitudes toward implementation of EBPs, as part of standardised training protocols.