Assessing physician leadership styles: application of the situational leadership model to transitions in patient acuity.

BACKGROUND: The situational leadership model suggests that an effective leader adapts leadership style depending on the followers' level of competency. PURPOSE: We assessed the applicability and reliability of the situational leadership model when observing residents in simulated hospital floor-based scenarios. METHODS: Resident teams engaged in clinical simulated scenarios. Video recordings were divided into clips based on Emergency Severity Index v4 acuity scores. Situational leadership styles were identified in clips by two physicians. Interrater reliability was determined through descriptive statistical data analysis. RESULTS: There were 114 participants recorded in 20 sessions, and 109 clips were reviewed and scored. There was a high level of interrater reliability (weighted kappa r = .81) supporting situational leadership model's applicability to medical teams. A suggestive correlation was found between frequency of changes in leadership style and the ability to effectively lead a medical team. CONCLUSIONS: The situational leadership model represents a unique tool to assess medical leadership performance in the context of acuity changes.

An educational intervention to improve cost-effective care among medicine housestaff: a randomized controlled trial.

PURPOSE: High medical costs create significant burdens. Research indicates that doctors have little awareness of costs. This study tested whether a brief educational intervention could increase residents' awareness of cost-effectiveness and reduce costs without negatively affecting patient outcomes. METHOD: The authors conducted a clustered randomized controlled trial of 33 teams (96 residents) at an internal medicine residency program (2009-2010). The intervention was a 45-minute teaching session; residents reviewed the hospital bill of a patient for whom they had cared and discussed reducing unnecessary costs. Primary outcomes were laboratory, pharmacy, radiology, and total hospital costs per admission. Secondary measures were length of stay (LOS), intensive care unit (ICU) admission, 30-day readmission, and 30-day mortality. Multivariate adjustment controlled for patient demographics and health. A follow-up survey assessed resident attitudes three months later. RESULTS: Among 1,194 patients, there were no significant cost differences between intervention and control groups. In the intervention group, 30-day readmission was higher (adjusted odds ratio 1.51, P = .010). There was no effect on LOS or the composite outcome of readmission, mortality, and ICU transfer. In a subgroup analysis of 835 patients newly admitted during the study, the intervention group incurred $163 lower adjusted lab costs per admission (P = .046). The follow-up survey indicated persistent differences in residents' exposure to concepts of cost-effectiveness (P = .041). CONCLUSIONS: A brief intervention featuring a discussion of hospital bills can fill a gap in resident education and reduce laboratory costs for a subset of patients, but may increase readmission risk.

Observation of clinical teaching: interest in a faculty development program for surgeons.

OBJECTIVES: Observation of clinical teaching is a powerful tool to develop faculty teaching skills. However, the process of being observed can be intimidating for any educator. Our aim is to assess interest in an Observation of Teaching Program within an academic surgical department. DESIGN: An electronic survey asking faculty to indicate interest in participation in a faculty development program that consists of a peer, expert, and/or cross-disciplinary physician observation of teaching was used. Faculty members were also asked whether they would like to observe other faculty as part of a peer-review track. The results were compiled for descriptive statistical analysis. SETTING: Electronic survey. PARTICIPANTS: In all, 46 faculty, all of whom have assigned medical student and resident teaching responsibilities, were introduced to the Observation of Teaching Program and surveyed on their interest in participating. RESULTS: A total of 87% (40/46) of faculty responded after 2 e-mails and 75% (30/40) indicated interest in the Observation of Teaching Program. All faculty who responded positively indicated interest in expert review (30/30), 90% (27/30) in peer review, 87% (26/30) in surgeon review, and 83% (25/30) in cross-disciplinary physician review. A total of 48% (19/40) indicated interest in observing others. Of those who were not interested in the Observation of Teaching Program, restrictions on time (4/10), not enough clinical care responsibilities (2/10), not wanting to be watched (2/10), and program did not seem effective (1/10) were cited as reasons for not participating. CONCLUSIONS: Surgical faculty are interested in being observed and receiving feedback about their clinical teaching by experts, peers, colleagues, and cross-disciplinary physicians. Professional development programs for surgeons should consider observation as a teaching methodology.

Evaluation of a redesign initiative in an internal-medicine residency.

BACKGROUND: Several organizations have advocated for comprehensive redesign of graduate medical training, but the effect that residency redesign will have on measures of patient satisfaction, resident and intern (trainee) satisfaction, and patient care is unknown. METHODS: We designed an experimental inpatient-medicine service with reduced resident workload comprising two teams, with each team consisting of two attending physicians, two residents, and three interns. Attending physicians, selected for their teaching prowess, supervised the teams throughout the workday and during bedside team-teaching rounds. This experimental model was compared with a control model comprising two teams, with each consisting of one resident and two interns, plus multiple supervising attending physicians who volunteered to participate. Patients were alternately assigned to the experimental teams and the control teams, subject to limits on the number of patients interns are allowed to admit. RESULTS: Over a 12-month period, 1892 patients were assigned to the experimental teams and 2096 to the control teams; the average census per intern was 3.5 and 6.6 patients, respectively. Overall satisfaction was significantly higher among trainees on the experimental teams than among those on the control teams (78% and 55%, respectively; P=0.002). As compared with the control teams, the experimental teams were not associated with a higher average length of patient stay or readmission rate; adherence to standards for quality of inpatient care was similar in both groups of teams. Interns on the experimental teams spent more time in learning and teaching activities than did interns on the control teams (learning: 20% of total time vs. 10%, P=0.01; teaching: 8% of total time vs. 2%, P=0.006). CONCLUSIONS: As compared with a traditional inpatient care model, an experimental model characterized by reduced trainee workload and increased participation of attending physicians was associated with higher trainee satisfaction and increased time for educational activities.