Design of a clinical competency committee to maximize formative feedback.

BACKGROUND: As the next phase in the roll-out of Next Accreditation System, US residency programs are to develop Clinical Competency Committees (CCCs) to formally implement outcome-based medical education objectives in the resident assessment process. However, any changes to an assessment system must consider balancing formative and summative tensions, flexibility and standardization tensions, fairness and transparency to learners, and administrative burden for faculty. OBJECTIVES/METHODS: In this article, one program discusses the approach one internal medicine residency took to create a developmental model CCC. In this model, a learner's mentor presents the argument for competence to the CCC, while a second reviewer presents challenges to that argument to the rest of the committee members. The CCC members provide other insights and make recommendations. The mentor presents the final committee recommendations to that resident, who then works with the mentor to develop a plan for future action. RESULTS: CCC second reviewers spent an average of 30.4 min (SD: 11.4) preparing for each resident's discussion, a duty performed 5-7 times every 6 months. Faculty development was associated with an increase in the number of action-oriented comments in the meeting minutes (3.2-4.1 comments per resident, p=0.001). CCC members and mentors gave higher Likert-type ratings than residents for fairness (4.8 vs. 4.0) and learning prioritization (4.7 vs. 4.2), but similar ratings for transparency (4.0 vs. 4.2). CONCLUSION: Developmental model CCCs may be feasible for residency programs, but faculty development may be necessary.

Effectiveness of iterative interventions to increase research productivity in one residency program.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires residency programs to expose residents to research opportunities. OBJECTIVE: The purpose of this study was to assess the impact of a series of iterative interventions to increase scholarly activity in one internal medicine residency. METHODS: Retrospective analysis of the effectiveness of a series of interventions to increase resident and faculty scholarly productivity over a 14-year period was performed using quality improvement methodology. Outcomes measured were accepted regional and national abstracts and PubMed indexed manuscripts of residents and faculty. RESULTS: Initially, regional meeting abstracts increased and then were supplanted by national meeting abstracts. Sustained gains in manuscript productivity occurred in the eighth year of interventions, increasing from a baseline of 0.01 publications/FTE/year to 1.57 publications/FTE/year in the final year measured. Run chart analysis indicated special cause variation associated with the interventions performed. CONCLUSIONS: Programs attempting to stimulate research production among faculty and residents can choose among many interventions cited in the literature. Since success of any group of interventions is likely additive and may take years to show benefit, measuring outcomes using quality improvement methodology may be an effective way to determine success.

The Group Objective Structured Clinical Experience: building communication skills in the clinical reasoning context.

OBJECTIVE: Students are rarely taught communication skills in the context of clinical reasoning training. The purpose of this project was to combine the teaching of communication skills using SPs with clinical reasoning exercises in a Group Objective Structured Clinical Experience (GOSCE) to study feasibility of the approach, the effect on learners' self-efficacy and attitude toward learning communication skills, and the effect of providing multiple sources of immediate, collaborative feedback. METHODS: GOSCE sessions were piloted in Pediatrics and Medicine clerkships with students assessing their own performance and receiving formative feedback on communication skills from peers, standardized patients (SPs), and faculty. The sessions were evaluated using a retrospective pre/post-training questionnaire rating changes in self-efficacy and attitudes, and the value of the feedback. RESULTS: Results indicate a positive impact on attitudes toward learning communication skills and self-efficacy regarding communication in the clinical setting. Also, learners considered feedback by peers, SPs, and faculty valuable in each GOSCE. CONCLUSION: The GOSCE is an efficient and learner-centered method to attend to multiple goals of teaching communication skills, clinical reasoning, self-assessment, and giving feedback in a formative setting. PRACTICE IMPLICATIONS: The GOSCE is a low-resource, feasible strategy for experiential learning in communication skills and clinical reasoning.

An initiative to improve adherence to evidence-based guidelines in the treatment of URIs, sinusitis, and pharyngitis.

BACKGROUND: Upper respiratory infections, acute sinus infections, and sore throats are common symptoms that cause patients to seek medical care. Despite well-established treatment guidelines, studies indicate that antibiotics are prescribed far more frequently than appropriate, raising a multitude of clinical issues. METHODS: The primary goal of this study was to increase guideline adherence rates for acute sinusitis, pharyngitis, and upper respiratory tract infections (URIs). This study was the first Plan-Do-Study-Act (PDSA) cycle in a quality improvement program at an internal medicine resident faculty practice at a university-affiliated community hospital internal medicine residency program. To improve guideline adherence for respiratory infections, a package of small-scale interventions was implemented aimed at improving patient and provider education regarding viral and bacterial infections and the necessity for antibiotics. The data from this study was compared with a previously published study in this practice, which evaluated the adherence rates for the treatment guidelines before the changes, to determine effectiveness of the modifications. After the first PDSA cycle, providers were surveyed to determine barriers to adherence to antibiotic prescribing guidelines. RESULTS: After the interventions, antibiotic guideline adherence for URI improved from a rate of 79.28 to 88.58% with a p-value of 0.004. The increase of adherence rates for sinusitis and pharyngitis were 41.7-57.58% (p=0.086) and 24.0-25.0% (p=0.918), respectively. The overall change in guideline adherence for the three conditions increased from 57.2 to 78.6% with the implementations (p<0.001). In planning for future PDSA cycles, a fishbone diagram was constructed in order to identify all perceived facets of the problem of non-adherence to the treatment guidelines for URIs, sinusitis, and pharyngitis. From the fishbone diagram and the provider survey, several potential directions for future work are discussed. CONCLUSIONS: Passive interventions can result in small changes in antibiotic guideline adherence, but further PDSA cycles using more active methodologies are needed.

Improvement in asthma quality of life in patients enrolled in a prospective study to increase lifestyle physical activity.

OBJECTIVE: Asthma patients know the benefits of exercise but often avoid physical activity because they are concerned that it will exacerbate asthma. The objective of this analysis was to assess longitudinal asthma status in 256 primary care patients in New York City enrolled in a trial to increase lifestyle physical activity. METHODS: Patients were randomized to two protocols to increase physical activity during a period of 12 months. At enrollment, patients completed the Asthma Quality of Life Questionnaire (AQLQ) and the Asthma Control Questionnaire (ACQ) and received asthma self-management instruction through an evaluative test and workbook. Exercise and self-management were reinforced every 2 months. The AQLQ was repeated every 4 months and the ACQ was repeated at 12 months. RESULTS: The mean age was 43 years and 75% were women. At 12 months there were clinically important increases in physical activity with no differences between groups; thus, data were pooled for asthma analyses. The enrollment AQLQ score was 5.0 ± 1.3 and increased to 5.9 ± 1.1 corresponding to a clinically important difference. Correlations between AQLQ and physical activity were approximately 0.35 (p < .0001) at each time point. In a mixed effects model, the variables associated with improvement in AQLQ scores over time were male sex, less severe asthma, not taking asthma maintenance medications, fewer depressive symptoms, and increased physical activity (all variables, p < .03). According to the ACQ, asthma was well controlled in 38% at enrollment and in 60% at 12 months (p < .0001). CONCLUSION: With attention to self-management, increased physical activity did not compromise asthma control and was associated with improved asthma.

Increasing physical activity in patients with asthma through positive affect and self-affirmation: a randomized trial.

BACKGROUND: Patients with asthma engage in less physical activity than peers without asthma. Protocols are needed to prudently increase physical activity in asthma patients. We evaluated whether an educational intervention enhanced with positive-affect induction and self-affirmation was more effective than the educational protocol alone in increasing physical activity in asthma patients. METHODS: We conducted a randomized trial in New York City from September 28, 2004, through July 5, 2007; of 258 asthma patients, 252 completed the trial. At enrollment, control subjects completed a survey measuring energy expenditure, made a contract to increase physical activity, received a pedometer and an asthma workbook, and then underwent bimonthly follow-up telephone calls. Intervention patients received this protocol plus small gifts and instructions in fostering positive affect and self-affirmation. The main outcome was the within-patient change in energy expenditure in kilocalories per week from enrollment to 12 months with an intent-to-treat analysis. RESULTS: Mean (SD) energy expenditure at enrollment was 1767 (1686) kcal/wk among controls and 1860 (1633) kcal/wk among intervention patients (P = .65) and increased by 415 (95% CI, 76-754; P = .02) and 398 (95% CI, 145-652; P = .002) kcal/wk, respectively, with no difference between groups (P = .94). For both groups, energy expenditure was sustained through 12 months. No adverse events were attributed to the trial. In multivariate analysis, increased energy expenditure was associated with less social support, decreased depressive symptoms, more follow-up calls, use of the pedometer, fulfillment of the contract, and the intervention among patients who required urgent asthma care (all P < .10, 2-sided test). CONCLUSIONS: A multiple-component protocol was effective in increasing physical activity in asthma patients, but an intervention to increase positive affect and self-affirmation was not effective within this protocol. The intervention may have had some benefit, however, in the subgroup of patients who required urgent asthma care during the trial. Trial Registration clinicaltrials.gov Identifier: NCT00195117.

Psychological and somatic symptoms in screening for depression in asthma patients.

Correctly identifying asthma patients who need treatment for depression is part of comprehensive care. The objective of this study was to compare the prevalence of depressive symptoms measured by the short-form Center for Epidemiologic Studies Depression Scale (CESD-SF), which measures somatic and psychological symptoms, with the original and short-form Geriatric Depression Scale (GDS and GDS-SF), which measure only psychological symptoms. In total, 257 asthma patients (mean age 42 years, 75% women) completed the GDS (score range 0-30, positive screen > or = 11) and the CESD-SF (score range 0-30, positive screen > or = 10). The performance of each scale was compared to clinical diagnoses of depressive disorders reported by physicians using a skill score analysis. Twenty percent of patients had GDS scores > or = 11 and 32% had CESD-SF scores > or = 10. The somatic symptom of restless sleep was the most common CESD-SF symptom and the symptom that contributed most to the total score. The GDS had a skill score of +.16 (+1 = maximum possible, 0 = best guess) and the CESD-SF had a skill score of -.02 compared to physician-reported depressive disorders. Similar results were found for the GDS-SF. Thus, more patients had a positive CESD-SF screen, which was attributable mostly to a somatic sleep symptom that overlaps with asthma symptoms, and the GDS was more consistent with physicians' reports of depressive disorders.

Patient-reported and physician-reported depressive conditions in relation to asthma severity and control.

BACKGROUND: Depressive conditions in asthma patients have been described mostly from patient reports and less often from physician reports. While patient reports can encompass multiple symptoms, physician assessments can attribute symptoms to a mental health etiology. Our objectives were to identify associations between patient- and physician-reported depressive conditions and asthma severity and control. METHODS: Patient-reported depressive symptoms were obtained using the Geriatric Depression Scale (GDS) [possible score 0 to 30; higher score indicates more depressive symptoms]. Patients were categorized as having a physician-reported depressive disorder if they had the following: a diagnosis of depression, depressive symptoms described in medical charts, or were prescribed antidepressants at doses used to treat depression. Patients also completed the Severity of Asthma Scale (SOA) [possible score 0 to 28; higher score indicates more severe] and the Asthma Control Questionnaire (ACQ) [possible score 0 to 6; higher score indicates worse control]. RESULTS: Two hundred fifty-seven patients were included in this analysis (mean age, 42 years; 75% women). Mean SOA and ACQ (+/- SD) scores were 5.9 +/- 4.2 and 1.4 +/- 1.2, respectively; and mean GDS score was 6.3 +/- 6.4. After adjusting for age, sex, race, Latino ethnicity, education, medication adherence, body mass index, and smoking status, patient-reported depressive symptoms were associated with asthma severity (p = 0.007) and with asthma control (p = 0.0007). In contrast, physician-reported depressive disorders were associated with asthma severity (p = 0.04) but not with asthma control (p = 0.22) after adjusting for covariates. CONCLUSIONS: Physician- and patient-reported depressive conditions were associated with asthma severity. In contrast, patient-reported depressive symptoms were more closely associated with asthma control than were physician-reported depressive disorders. Identifying associations between depressive conditions and asthma severity and control is necessary to concurrently treat these conditions in this population. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00195117.

Measuring physical activity in asthma patients: two-minute walk test, repeated chair rise test, and self-reported energy expenditure.

Although prudent exercise is recommended for most patients with well-controlled asthma, many patients avoid exercise and physical activity because they are concerned about triggering asthma. In a sample of 258 asthma patients (mean age 42 years, 75% women), the objectives of this study were to assess the two-minute walk test and the repeated chair rise test and to compare results to self-reported physical activity recorded with the Paffenbarger Physical Activity and Exercise Index (PAEI). Patients walked a mean of 510 feet, required a mean of 14 seconds for the chair rise test, and reported a mean of 1,810 kilocalories per week from activities, mostly walking. In multivariable analysis, male sex, younger age, more education, lower body mass index, and better short-term asthma control, but not long-term asthma severity, were associated with better performance-based test results and more self-reported physical activity. Better short-term control also was associated with less breathing and leg exertion during both tests. Correlations between the PAEI and performance-based tests were approximately 0.38. Performance-based and self-reported measures provide information about various aspects of exercise capacity and can be used during routine clinical practice to assess physical activity in asthma patients.

Barriers and facilitators to healthy physical activity in asthma patients.

Preliminary evidence indicates that asthma patients limit exercise and healthy lifestyle activities to avoid respiratory symptoms. This self-imposed decrease in activity, even among those with mild disease, may predispose to long-term general health risks. The objectives of this qualitative study were to determine patients' views about exercise and lifestyle activities and to determine if these views varied depending on asthma characteristics. During in-person interviews, 60 patients were asked open-ended questions about asthma and perceived barriers and facilitators to exercise and lifestyle activities, particularly walking. Responses were coded and corroborated by independent investigators and then compared according to asthma severity, knowledge, self-efficacy, and attitudes. Although most patients acknowledged the importance of exercise, many either limited or did not participate in exercise because of asthma and other conditions. Patients cited both internal and external barriers to exercise, such as lack of motivation, time constraints, and extreme weather affecting asthma. Patients identified multiple facilitators, such as social support and the desire to be healthy. Lifestyle activities were preferred over formal exercise regimens. Patients with more severe disease were more likely to believe that exercise was not good for asthma. Patients with less knowledge, less self-efficacy, and worse attitudes toward asthma also were more likely to have negative perspectives about exercise. In conclusion, for many patients, asthma is a deterrent to physical activity and predisposes to inactivity. Developing interventions to foster prudent lifestyle activities and exercise among asthma patients should be a priority to decrease long-term health risks.

Specifying student-patient encounters, web-based case logs, and meeting standards of the liaison committee on medical education.

Standard ED-2 of the Liaison Committee on Medical Education (LCME) requires medical schools to specify the types of patients that students should encounter, the student's level of responsibility, and the appropriate setting for the encounter. The authors describe the process at Joan and Sanford I. Weill Medical College of Cornell University in New York City for meeting this standard through the development of a Web-based case log. The log permits the medical college to specify expectations for patient encounters and allows the students to record their encounters in an efficient, brief, and user-friendly manner. By downloading the student's reports directly into a database, the medical college can track successes and deficiencies in the student's clinical experiences. However, in response to a questionnaire administered in 2005, students generally expressed dissatisfaction with the case logs, which they described as intrusive busywork.

Ambulatory morning report: can it prepare residents for the American Board of Internal Medicine Examination?

We assessed the ability of a novel ambulatory morning report format to expose internal medicine residents to the breadth of topics covered by the American Board of Internal Medicine (ABIM) exam. Cases were selected by the Ambulatory Assistant Chief Residents and recorded in a logbook to limit duplication. We conducted a retrospective review of 406 cases discussed from July 1998 to July 2000 and cataloged each according to the primary content area. The percentage of cases in each area accurately reflected that covered by the ABIM exam, with little redundancy or over-selection of esoteric diseases. Our data suggest that a general medicine clinic is capable of exposing house staff to the wide breadth of internal medicine topics previously thought to be unique to subspecialty clinics.