An alternative practice model: residents transform continuity clinic and become systems thinkers.

BACKGROUND: A changing health care environment has created a need for physicians trained in health system improvement. Residency programs have struggled to teach and assess practice-based learning and improvement and systems-based practice competencies, particularly within ambulatory settings. INTERVENTION: We describe a resident-created and resident-led quality and practice-improvement council in an internal medicine continuity clinic. We conducted focus groups and report on residents' perspectives on council membership, practice management experiences, quality improvement projects, and resident satisfaction. METHOD: Focus groups were held from May 2009 to March 2010 with internal medicine residents (N  =  5/focus group) who participated in the Continuity Clinic Ownership in Resident Education (CCORE) council. Data were analyzed with a grounded theory approach. RESULTS: DURING THE FOCUS GROUPS, RESIDENTS RESPONDED TO THE QUESTION: "Do you have any new insights into delivering quality patient care in an outpatient clinic as a result of this experience (CCORE membership)?" The qualitative analysis resulted in 6 themes: systems thinking and systems-based care skills; improving quality of patient care; improved clinic efficiency; ownership of patients; need for improved communication of practice changes; and a springboard for research. CONCLUSIONS: CCORE residents participated in system changes and acquired leadership skills while working on practice-based and system problems in a clinic microsystem. We believe this model can be implemented by other residency programs to promote the development of systems thinking in residents, increase their ownership of continuity clinic, and empower them to implement system changes.

Isolated right superior vena cava drainage into the left atrium diagnosed noninvasively in the peripartum period.

Isolated right superior vena cava drainage into the left atrium is an extremely rare cardiac anomaly, especially in the absence of other cardiac abnormalities. Only 28 of 5,127 reported consecutive congenital cardiac cases involved superior vena cava drainage into the left atrium, and all were associated with other cardiac anomalies. Of 19 reported cases of right superior vena cava drainage into the left atrium, most patients have been children who were experiencing mild hypoxemia and cyanosis. Herein, we describe the case of a 34-year-old woman who presented with asymptomatic hypoxemia in the peripartum period. She was diagnosed to have isolated drainage of the right superior vena cava into the left atrium. To the best of our knowledge, this is the 1st reported instance of such diagnosis by use of noninvasive imaging only, without cardiac catheterization. We also review the medical literature that pertains to our patient's anomaly.