Evaluating the SPIKES Model for Improving Peer-to-Peer Feedback Among Internal Medicine Residents: a Randomized Controlled Trial.

BACKGROUND: Feedback improves trainee clinical performance, but the optimal way to provide it remains unclear. Peer feedback offers unique advantages but comes with significant challenges including a lack of rigorously studied methods. The SPIKES framework is a communication tool adapted from the oncology and palliative care literature for teaching trainees how to lead difficult conversations. OBJECTIVE: To determine if a brief educational intervention focused on the SPIKES framework improves peer feedback between internal medicine trainees on inpatient medicine services as compared to usual practice. DESIGN: Randomized, controlled trial at an academic medical center during academic year 2017-2018. PARTICIPANTS: Seventy-five PGY1 and 49 PGY2 internal medicine trainees were enrolled. PGY2s were randomized 1:1 to the intervention or control group. INTERVENTION: The intervention entailed a 30-min, case-based didactic on the SPIKES framework followed by a refresher email on SPIKES sent to PGY2s before each inpatient medicine rotation. PGY1s were blinded as to which PGY2s underwent the training. MAIN MEASURES: The primary outcome was PGY1 evaluation of the extent of feedback provided by PGY2s. Secondary outcomes included PGY1 report of feedback quality and PGY2 self-report of feedback quantity and quality. Outcomes were obtained via anonymous online survey and reported using a Likert scale with a range of one to four. KEY RESULTS: PGY1s completed 207 surveys (51% response rate) and PGY2s completed 61 surveys (42% response rate). PGY1s reported a higher extent of feedback (2.5 vs 2.2; p = 0.02; Cohen's d = 0.31), more specific feedback (2.3 vs 2.0; p < 0.01; d = 0.33), and higher satisfaction with feedback (2.6 vs 2.2; p < 0.01; d = 0.47) from intervention PGY2s. There were no significant differences in PGY2 self-reported outcomes. CONCLUSIONS: With modest implementation requirements and notable limitations, a brief educational intervention focused on SPIKES increased PGY1 perception of the extent, specificity, and satisfaction with feedback from PGY2s.

Quantitative Study of the Characteristics of Effective Internal Medicine Noon Conference Presentations.

Background Increasing demands on residents' time have made it critically important to maximize the effectiveness of didactic activities and motivate independent study. Objective Our aim was to correlate characteristics of noon conferences with internal medicine (IM) residents' ratings of perceived effectiveness and intent to pursue independent reading. Methods We assessed characteristics of each noon conference by direct observation using predetermined metrics. We surveyed IM residents to assess their perception of the conference's effectiveness and their intention to pursue additional reading. A variety of modeling techniques were used to discern meaningful correlations of effectiveness and motivation. Results A total of 649 evaluations of 29 conferences were submitted by 153 of 185 (83%) residents in the program. Median effectiveness score was 6 (on a scale of 1 to 7). Clinicopathological conferences had 0.55-point higher effectiveness scores than traditional conferences (P = .011). In multivariable analyses focusing on traditional conferences, summary statement inclusion was significantly associated with 0.43-point higher effectiveness scores (P = .016), and having resident speakers was associated with 0.50-point higher effectiveness scores than unfamiliar faculty (P = .045). Conferences with higher effectiveness scores had significantly higher proportions of respondents indicating intention to read. Conclusions This is the first study to quantitatively assess correlations of high effectiveness ratings of noon conferences in a residency program. Intention to read improved with increasing effectiveness scores of conferences, suggesting residents are more inclined to pursue self-directed learning when topics are well presented. Considering these attributes in designs of didactic sessions may enhance their educational value.

Beyond Continuing Medical Education: Clinical Coaching as a Tool for Ongoing Professional Development.

PROBLEM: For most physicians, the period of official apprenticeship ends with the completion of residency or fellowship, yet the acquisition of expertise requires ongoing opportunities to practice a given skill and obtain structured feedback on one's performance. APPROACH: In July 2013, the authors developed a clinical coaching pilot program to provide early-career hospitalists with feedback from a senior clinical advisor (SCA) at Massachusetts General Hospital. A Hospital Medicine Unit-wide retreat was held to help design the SCA role and obtain faculty buy-in. Twelve SCAs were recruited from hospitalists with more than five years of experience; each served as a clinical coach to 28 early-career hospitalists during the pilot. Clinical narratives and programmatic surveys were collected from SCAs and early-career hospitalists. OUTCOMES: Of 25 responding early-career hospitalists, 23 (92%) rated the SCA role as useful to very useful, 20 (80%) reported interactions with the SCA led to at least one change in their diagnostic approach, and 13 (52%) reported calling fewer subspecialty consults as a result of guidance from the SCA. In response to questions about professional development, 18 (72%) felt more comfortable as an independent physician following their interactions with the SCA, and 19 (76%) thought the interactions improved the quality of care they delivered. NEXT STEPS: To better understand the impact and generalizability of clinical coaching, a larger, longitudinal study is required to look at patient and provider outcomes in detail. Further refinement of the SCA role to meet faculty needs is needed and could include faculty development.

Medicine Resident Preparedness to Diagnose and Treat Substance Use Disorders: Impact of an Enhanced Curriculum.

BACKGROUND: The authors' previous study found that despite caring for many patients with addiction, most Massachusetts General Hospital (MGH) internal medicine residents feel unprepared to treat substance use disorders (SUDs) and rate SUD instruction during training as fair or poor. This follow-up study evaluates the impact of an enhanced curriculum on resident perceptions of the quality of instruction, knowledge base, and self-perceived preparedness to diagnose and treat SUDs. METHODS: Based on the findings of the earlier study, an enhanced SUD curriculum was designed and delivered to MGH medicine residents. Impact of the curriculum was evaluated using the same Web-based survey that was administered in the earlier study to compare pre- and posttest results. RESULTS: The authors' earlier study found that 75% of residents felt prepared to diagnose and 37% to treat SUDs and 45% of residents rated the overall quality of SUD instruction as good or excellent. Following the curriculum intervention, 87% of residents reported feeling prepared to diagnose (P=.028) and 60% to treat (P=.002) SUDs. Three quarters of residents rated the overall quality of instruction as good or excellent (P<.001), and 98% reported residency curriculum had a positive impact on their preparedness to care for patients with a SUDs. Residents who reported receiving an adequate amount of SUD instruction were more likely to feel prepared to diagnose and treat addiction (P<.001). Thirty-one percent of residents still rated the overall amount of SUD instruction as too little. The intervention did not significantly improve answers to knowledge questions. CONCLUSIONS: An enhanced SUDs curriculum for medicine residents increased self-perceived preparedness to diagnose and treat SUDs and educational quality ratings. However, there was no significant change in knowledge. Implementation of a more comprehensive curriculum and evaluation at other sites are necessary to determine the ideal SUD training model.

Case records of the Massachusetts General Hospital: Case 5-2014: 2014: A 59-year-old man with fever, confusion, thrombocytopenia, rash, and renal failure.

A 59-year-old man was admitted to this hospital because of fever, confusion, rash, thrombocytopenia, and renal failure, 10 days after a hunting trip in the Nevada valley. Diagnostic procedures were performed, and diagnostic test results were received from another hospital.

Internal medicine residents' training in substance use disorders: a survey of the quality of instruction and residents' self-perceived preparedness to diagnose and treat addiction.

BACKGROUND: Resident physicians are the direct care providers for many patients with addiction. This study assesses residents' self-perceived preparedness to diagnose and treat addiction, measures residents' perceptions of the quality of addictions instruction, and evaluates basic knowledge of addictions. METHODS: A survey was e-mailed to 184 internal medicine residents at Massachusetts General Hospital in May 2012. RESULTS: Responses were obtained from 55% of residents. Residents estimated that 26% of inpatients they cared for met criteria for a substance use disorder (SUD). Twenty-five percent of residents felt unprepared to diagnose and 62% felt unprepared to treat addiction. Only 13% felt very prepared to diagnose addiction. No residents felt very prepared to treat addiction. Preparedness to diagnose or treat addiction did not differ significantly across postgraduate year (PGY) level. Fifty-five percent rated the overall instruction in addictions as poor or fair. Seventy-two percent of residents rated the quality of addictions training as poor or fair in the outpatient clinical setting, and 56% in the inpatient setting. No resident answered all 6 knowledge questions correctly. Slightly more than half correctly identified the mechanism of buprenorphine and 19% correctly answered a question about naltrexone. Nine percent of residents responded that someone had expressed concern about the respondent's substance use. CONCLUSIONS: Despite providing care for a substantial population with addiction, the majority of internal medicine residents in this study feel unprepared to treat SUDs. More than half rate the quality of addictions instruction as fair or poor. Structured and comprehensive addictions curriculum and faculty development are needed to address the deficiencies of the current training system.