Jay Orlander - Academia.edu (original) (raw)
Papers by Jay Orlander
BMC health services research, Jan 24, 2018
Electronic consultation is an emerging mode of specialty care delivery that allows primary care p... more Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion. Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 earl...
Journal of telemedicine and telecare, 2018
Introduction E-consultations (e-consults) were implemented at VA medical centers to improve acces... more Introduction E-consultations (e-consults) were implemented at VA medical centers to improve access to specialty care. Cardiology e-consults are among the most commonly requested, but little is known about how primary care providers (PCPs) use cardiology e-consults to access specialty care. Methods This is a retrospective analysis of 750 patients' medical charts with cardiology e-consults requested by medical providers (October 2013-September 2015) in the VA New England Healthcare System. We described the patients and referring provider characteristics, and e-consult questions. We reviewed cardiologists' responses and examined their recommendations. Results Among the 424 e-consults requested from PCPs, 92.7% were used to request answers to clinical questions, while 7.3% were used for administrative purposes. Among the 393 e-consults with clinical questions, 60 e-consults were regarding preoperative management; these questions most commonly addressed general risk assessment ( ...
Diabetes Care
Rigorous evidence is lacking whether online games can improve patients' longer-term health outcom... more Rigorous evidence is lacking whether online games can improve patients' longer-term health outcomes. We investigated whether an online team-based game delivering diabetes self-management education (DSME) to patients via e-mail or mobile application (app) can generate longer-term improvements in hemoglobin A 1c (HbA 1c). RESEARCH DESIGN AND METHODS Patients (n = 456) on oral diabetes medications with HbA 1c ‡58 mmol/mol were randomly assigned between a DSME game (with a civics booklet) and a civics game (with a DSME booklet). The 6-month games sent two questions twice weekly via e-mail or mobile app. Participants accrued points based on performance, with scores posted on leaderboards. Winning teams and individuals received modest financial rewards. Our primary outcome measure was HbA 1c change over 12 months. RESULTS DSME game patients had significantly greater HbA 1c reductions over 12 months than civics game patients (28 mmol/mol [95% CI 210 to 27] and 25 mmol/mol [95% CI 27 to 23], respectively; P = 0.048). HbA 1c reductions were greater among patients with baseline HbA 1c >75 mmol/mol: 216 mmol/mol [95% CI 221 to 212] and 29 mmol/mol [95% CI 214 to 25] for DSME and civics game patients, respectively; P = 0.031. CONCLUSIONS Patients with diabetes who were randomized to an online game delivering DSME demonstrated sustained and meaningful HbA 1c improvements. Among patients with poorly controlled diabetes, the DSME game reduced HbA 1c by a magnitude comparable to starting a new diabetes medication. Online games may be a scalable approach to improve outcomes among geographically dispersed patients with diabetes and other chronic diseases. Diabetes self-management education (DSME) is a core component of comprehensive quality care of type 2 diabetes (1,2). There is consensus on the appropriate DSME curricular elements (3) but not necessarily how it should be delivered. DSME can generate short-term (,6 months) positive effects on glucose control, but these early gains often dissipate quickly (4-8). A meta-analysis showed that two-thirds of hemoglobin A 1c (HbA 1c) change attributable to DSME is lost in the 1-3 months after completion (9).
Open Forum Infectious Diseases
Medical Education Online, 2016
Chalk talkswhere the teacher is equipped solely with a writing utensil and a writing surfacehave ... more Chalk talkswhere the teacher is equipped solely with a writing utensil and a writing surfacehave been used for centuries, yet little has been written about strategies for their use in medical education. Structured education proximal to patient encounters (during rounds, at the bedside, or in between patients in clinic) maximizes the opportunities for clinical learning. This paper presents a strategy to bring mini-chalk talks (MCTs) to the bedside as a practical way to provide relevant clinical teaching by visually framing teachable moments. Grounded in adult learning theory, MCTs leverage teaching scripts to facilitate discussion, involve learners at multiple levels, and embrace the increased retention associated with visual aids. These authors provide specific recommendations for the design and implementation of MCT sessions including what topics work well, how to prepare, and how to involve and engage the learners.
Clinical Infectious Diseases, 2017
Southern Med J, 1999
Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance ... more Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance of education in the decision to execute an AD, I did this study to determine the rate at which health care workers (a medically educated group) and their families execute ADs. All clinical staff at an urban tertiary care VA medical center were surveyed. Of 730 surveys mailed, 553 (76%) were returned, and 18% of respondents executed an AD. Age was the only variable that predicted execution of an AD. End-of-life medical decision-making discussions with family members were reported frequently (with spouses 74%, parents 50%). Health care workers do not appear to complete ADs at a rate any higher than the general population. Thus, education may be necessary, but alone it appears insufficient to increase use of ADs. Frequent family discussions occur among health care providers and their families. Such discussions may be an important outcome in their own right.
Http Dx Doi Org 10 1080 10401334 2013 827979, Oct 1, 2013
Clinical teaching has moved from the bedside to conference rooms; many reasons are described for ... more Clinical teaching has moved from the bedside to conference rooms; many reasons are described for this shift. Yet, essential clinical skills, professionalism, and humanistic patient interactions are best taught at the bedside. Clinical teaching has moved from the bedside to conference rooms; many reasons are described for this decline. This study explored perceptions of teachers and learners on the value of bedside teaching and the humanistic dimensions of bedside interactions that make it imperative to shift clinical teaching back to the bedside. Focus group methodology was used to explore teacher and learner opinions. Four teacher groups consisted of (a) Chief Residents, (b) Residency Program Directors, (c) skilled bedside teachers, and (d) a convenience group of other Department of Medicine faculty at Boston University School of Medicine. Six learner groups consisted 2 each of 3rd-year students, PGY1 medicine residents, and PGY2 medicine residents. Each discussion lasted 60 to 90 minutes. Sessions were audiotaped, transcribed, and analyzed using qualitative methods. Teachers and learners shared several opinions on bedside teaching, particularly around humanistic aspects of bedside interactions. The key themes that emerged included (a) patient involvement in discussions, (b) teachers as role models of humanism, (c) preserving learner autonomy, (d) direct observation and feedback of learners at the bedside, (e) interactions with challenging patients, and (e) admitting limitations. Within these themes, participants noted some behaviors best avoided at the bedside. Teachers and learners regard the bedside as a valuable venue in which to learn core values of medicine. They proposed many strategies to preserve these humanistic values and improve bedside teaching. These strategies are essential for true patient-centered care.
Academic Medicine, 2016
In this article, the authors reexamine the Ambulatory Diagnostic and Treatment Center (ADTC) mode... more In this article, the authors reexamine the Ambulatory Diagnostic and Treatment Center (ADTC) model, which uniquely combines the education of trainees with the care of referred patients at one Veterans Affairs medical center. As an ambulatory clinic with an inpatient mind-set, the ADTC uses a series of closely spaced outpatient appointments that are longer than typical ambulatory visits, offering a VIP-level of evaluation with the patient-centered goal of expedited diagnosis and treatment. Faculty triage patients by weighing factors such as urgency, educational value, complexity, and instability of diseases in conjunction with the resources, availability, and appropriateness of other services within the medical center.The ADTC's unique focus on the education of trainees in comparison with other clinical rotations is evident in the ratio of learning to patient care. This intensive training environment expects postgraduate year 2 and 3 internal medicine residents and fourth-year medical students to read, reflect, and review literature daily. This mix of education and care delivery is ripe for reexploration in light of recent calls for curriculum reform amidst headlines exposing delays in veterans' access to care.A low-volume, high-intensity clinic like the ADTC can augment the clinical services provided by a busy primary care and subspecialty workforce without losing its emphasis on education. Other academic health centers can learn from this model and adapt its structure in settings where accountable care organizations and education meet.
Academic Medicine Journal of the Association of American Medical Colleges, Oct 1, 2002
The morbidity and mortality conference (M&amp... more The morbidity and mortality conference (M&MC) appears to have sprung from the efforts of physicians to improve practice through the examination of medical errors and bad outcomes. The modern M&MC has had limited examination (and almost none outside surgery and anesthesia), but may be straying from the precepts from which it evolved. Learning from one's errors is important, but confronting them is difficult and is particularly delicate when done in conference. If the effort is successful, it can serve as a model. If unsuccessful, it can instead convey the lesson that attempting to learn from error is at best unproductive and at worst unpleasant. Thus, the M&MC is a double-edged sword, and particular attention should be given to the way that it is conducted. The authors review the historical roots and current literature on the M&MC, discusses relevant literature on medical error, and offers a definition, guiding principles, and a set of guidelines for a modern internal medicine M&MC. The ideas are presented not as a blueprint, but rather to stimulate a debate on the merits of establishing a framework for a working model, in order to refocus on the tradition of self-analysis and critical thinking in a manner that is productive for all participants.
Nihon Naika Gakkai Zasshi, 2008
Journal of women's health (2002), 2015
In 2004, the CDC and the American Cancer Society (ACS) published performance guidelines recommend... more In 2004, the CDC and the American Cancer Society (ACS) published performance guidelines recommending a validated method of clinical breast exams (CBE) using the vertical strips method (VSM) along with other key exam components. We examined the use of the VSM by academic medicine physicians and identified predictor variables for its adoption. Clinician educators in the Society of General Internal Medicine (SGIM) and physicians in the Society of Teachers of Family Medicine (STFM) were administered web-based surveys on CBE practices in 2009. A total of 1,772 (42%) physicians responded. Only 40% of respondents reported using the VSM, compared with 53% using the circular search method. Variables and their odds ratios (ORs) associated with an increase adoption of the VSM were having a primary teaching hospital affiliation (OR 1.4 [1.1, 1.9]), having taken a course on breast health or breast cancer in the past 5 years (OR 1.5 [1.1, 2.0]), and having completed residency in the past 5 years ...
Family medicine, 2010
Community health centers are facing a shortage of primary care physicians at a time when governme... more Community health centers are facing a shortage of primary care physicians at a time when government plans have called for an expansion of community health center programs. To succeed with this expansion, community health centers require additional well-trained physician leadership. Our objective was to ascertain how medical directors obtain leadership skills in an attempt to identify the best methods and venues for providing future leadership training programs. Using recorded interviews and focus group data with community health center medical directors, we identified patterns and themes through cross-case content analysis to determine leadership training needs in underserved settings. Medical directors often enter positions unprepared and can quickly become frustrated by an inability to make system improvements. Medical directors seek multiple ways to obtain the leadership skills necessary, including conferences, peer networking, mentorship, and formal degree training. Many directo...
Journal of the National Medical Association, 2006
To describe black residents' perceptions of the impact of race on medical training. Open-ende... more To describe black residents' perceptions of the impact of race on medical training. Open-ended interviews were conducted of black physicians in postgraduate year 22 who had graduated from U.S. medical schools and were enrolled in residency programs at one medical school. Using Grounded Theory tenets of qualitative research, data was culled for common themes through repeated readings; later, participants commented on themes from earlier interviews. Of 19 participants 10 were male, distributed evenly among medical and surgical fields. Four major themes emerged from the narratives: discrimination, differing expectations, social isolation and consequences. Participants' sense of being a highly visible minority permeated each theme. Overt discrimination was rare. Participants perceived blacks to be punished more harshly for the same transgression and expected to perform at lower levels than white counterparts. Participants' suspicion of racism as a motivation for individual a...
Journal of the American Geriatrics Society, 1992
To examine the relationship between exogenous estrogen use and risk of clinically diagnosed urina... more To examine the relationship between exogenous estrogen use and risk of clinically diagnosed urinary tract infection (UTI) in older women. A case-control study. Two hundred seventy-six general practices. Cases (n = 3,616) were women, age 50-69 years, with a first recorded UTI in the calendar years 1989 or 1990. Controls (n = 19,162) were matched for age and practice. Clinical diagnosis of UTI. Women using estrogens for greater than or equal to 1 year had an increased risk of being diagnosed with a UTI compared to non-users, crude odds ratio (OR) 1.9 (95% CI 1.5-2.2). All of this excess risk was observed in women with intact uteri, OR 2.1 (CI 1.7-2.7). Hysterectomized women had no increased risk, OR 1.1 (CI 0.8-1.5). Controlling for diabetes, neurologic deficit, atrophic vaginitis, incontinence, and age did not affect the observed associations. Estrogen use is associated with an increased risk of UTI in older women with intact uteri but not in hysterectomized women. This observed diff...
Southern Medical Journal, 1999
Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance ... more Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance of education in the decision to execute an AD, I did this study to determine the rate at which health care workers (a medically educated group) and their families execute ADs. All clinical staff at an urban tertiary care VA medical center were surveyed. Of 730 surveys mailed, 553 (76%) were returned, and 18% of respondents executed an AD. Age was the only variable that predicted execution of an AD. End-of-life medical decision-making discussions with family members were reported frequently (with spouses 74%, parents 50%). Health care workers do not appear to complete ADs at a rate any higher than the general population. Thus, education may be necessary, but alone it appears insufficient to increase use of ADs. Frequent family discussions occur among health care providers and their families. Such discussions may be an important outcome in their own right.
Medical Teacher, 2007
Little has been written on the art of using a board in clinical teaching. The technological devel... more Little has been written on the art of using a board in clinical teaching. The technological development of the white board appears to have coincided with that of the laptop computer and accompanying LCD projector, so that fewer and fewer teaching sessions appear to utilize the board as an efficient teaching tool. I have observed this most commonly among younger faculty who are most comfortable with technology and who may lack training and experience with a blank board. This paper offers suggestions on using the board in clinical teaching in order to enhance the educational process through better engagement of the learners.
Medical Education Online, 2006
Purpose: To develop a tool to assess the team leadership skills of internal medicine residents. M... more Purpose: To develop a tool to assess the team leadership skills of internal medicine residents. Method: A 27-item pilot instrument developed by two authors was distributed to interns on ward and intensive care unit teams at the end of rotations from a single institution's internal medicine residency program. These items were factor analyzed and reduced to a seven-item resident leadership scale (RLS). Validity of the instrument was assessed by comparing the rating on the RLS to scores on a validated measure of teaching skills provided at the same time and by the program director's global rating of team leadership skill for each resident at the completion of data collection. Results: The three principal components from the factor analysis explained 82 percent of the variance. By introspection we reduced the scale to the final 7-item RLS that had a Cronbach alpha reliability estimate of 0.95. 490 ratings on 134 individual residents were available for analysis. The RLS scores correlated highly with both the validated measure of teaching skill and the program director's ratings. Conclusion: The RLS has robust psychometric properties. It may provide a useful tool for a broader assessment of trainee skill if validated in other settings.
Journal of General Internal Medicine, 1991
To determine whether current fellowships in general internal medicine (FGIM) meet the perceived n... more To determine whether current fellowships in general internal medicine (FGIM) meet the perceived needs and objectives of physicians entering careers in academic internal medicine. A modified Delphi method yielded the 18 curricular elements included in the mailed survey. Participants outlined both actual and ideal fellowship experiences by rating the degree of emphasis of each curricular element on a Likert scale. Respondents then prioritized elements by rank-ordering them on perceived importance. Current job descriptions and opinions on related issues in FGIM were collected. Potential fellows, current fellows, and recent graduates were surveyed. Individuals were identified through the Society of General Internal Medicine associates' mailing list and solicitation of program directors. Nonfellow associates served as the proxy group for potential fellows. 579 surveys were mailed; 348 (60%) responses were received, of which 288 (50%) were suitable for analysis. Of all respondents, 38% were current fellows and 40% were recent graduates. When asked to prioritize educational needs during fellowship training, respondents ranked research methodology, ambulatory medicine, critical review of the literature, epidemiology, biostatistics, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curriculum as the top ten. Only minor deviations in rank order were found between graduates and nongraduates. Mean Likert scale scores for degree of emphasis of each curricular element in graduates' actual fellowships were compared with mean scores for graduates' ideal fellowship descriptions. High-priority elements that were perceived as adequately emphasized included research methodology, critical analysis of the literature, epidemiology, and biostatistics. High-priority elements that were perceived as inadequately emphasized included ambulatory medicine, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curricula. FGIM largely meet the expectations of their fellows for preparation for research responsibilities. However, several curricular elements concerned with preparation for future clinical and teaching responsibilities are perceived by graduates as underemphasized. These areas deserve increased emphasis during fellowship training to better prepare fellows for their future roles in academic general internal medicine.
BMC health services research, Jan 24, 2018
Electronic consultation is an emerging mode of specialty care delivery that allows primary care p... more Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion. Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 earl...
Journal of telemedicine and telecare, 2018
Introduction E-consultations (e-consults) were implemented at VA medical centers to improve acces... more Introduction E-consultations (e-consults) were implemented at VA medical centers to improve access to specialty care. Cardiology e-consults are among the most commonly requested, but little is known about how primary care providers (PCPs) use cardiology e-consults to access specialty care. Methods This is a retrospective analysis of 750 patients' medical charts with cardiology e-consults requested by medical providers (October 2013-September 2015) in the VA New England Healthcare System. We described the patients and referring provider characteristics, and e-consult questions. We reviewed cardiologists' responses and examined their recommendations. Results Among the 424 e-consults requested from PCPs, 92.7% were used to request answers to clinical questions, while 7.3% were used for administrative purposes. Among the 393 e-consults with clinical questions, 60 e-consults were regarding preoperative management; these questions most commonly addressed general risk assessment ( ...
Diabetes Care
Rigorous evidence is lacking whether online games can improve patients' longer-term health outcom... more Rigorous evidence is lacking whether online games can improve patients' longer-term health outcomes. We investigated whether an online team-based game delivering diabetes self-management education (DSME) to patients via e-mail or mobile application (app) can generate longer-term improvements in hemoglobin A 1c (HbA 1c). RESEARCH DESIGN AND METHODS Patients (n = 456) on oral diabetes medications with HbA 1c ‡58 mmol/mol were randomly assigned between a DSME game (with a civics booklet) and a civics game (with a DSME booklet). The 6-month games sent two questions twice weekly via e-mail or mobile app. Participants accrued points based on performance, with scores posted on leaderboards. Winning teams and individuals received modest financial rewards. Our primary outcome measure was HbA 1c change over 12 months. RESULTS DSME game patients had significantly greater HbA 1c reductions over 12 months than civics game patients (28 mmol/mol [95% CI 210 to 27] and 25 mmol/mol [95% CI 27 to 23], respectively; P = 0.048). HbA 1c reductions were greater among patients with baseline HbA 1c >75 mmol/mol: 216 mmol/mol [95% CI 221 to 212] and 29 mmol/mol [95% CI 214 to 25] for DSME and civics game patients, respectively; P = 0.031. CONCLUSIONS Patients with diabetes who were randomized to an online game delivering DSME demonstrated sustained and meaningful HbA 1c improvements. Among patients with poorly controlled diabetes, the DSME game reduced HbA 1c by a magnitude comparable to starting a new diabetes medication. Online games may be a scalable approach to improve outcomes among geographically dispersed patients with diabetes and other chronic diseases. Diabetes self-management education (DSME) is a core component of comprehensive quality care of type 2 diabetes (1,2). There is consensus on the appropriate DSME curricular elements (3) but not necessarily how it should be delivered. DSME can generate short-term (,6 months) positive effects on glucose control, but these early gains often dissipate quickly (4-8). A meta-analysis showed that two-thirds of hemoglobin A 1c (HbA 1c) change attributable to DSME is lost in the 1-3 months after completion (9).
Open Forum Infectious Diseases
Medical Education Online, 2016
Chalk talkswhere the teacher is equipped solely with a writing utensil and a writing surfacehave ... more Chalk talkswhere the teacher is equipped solely with a writing utensil and a writing surfacehave been used for centuries, yet little has been written about strategies for their use in medical education. Structured education proximal to patient encounters (during rounds, at the bedside, or in between patients in clinic) maximizes the opportunities for clinical learning. This paper presents a strategy to bring mini-chalk talks (MCTs) to the bedside as a practical way to provide relevant clinical teaching by visually framing teachable moments. Grounded in adult learning theory, MCTs leverage teaching scripts to facilitate discussion, involve learners at multiple levels, and embrace the increased retention associated with visual aids. These authors provide specific recommendations for the design and implementation of MCT sessions including what topics work well, how to prepare, and how to involve and engage the learners.
Clinical Infectious Diseases, 2017
Southern Med J, 1999
Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance ... more Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance of education in the decision to execute an AD, I did this study to determine the rate at which health care workers (a medically educated group) and their families execute ADs. All clinical staff at an urban tertiary care VA medical center were surveyed. Of 730 surveys mailed, 553 (76%) were returned, and 18% of respondents executed an AD. Age was the only variable that predicted execution of an AD. End-of-life medical decision-making discussions with family members were reported frequently (with spouses 74%, parents 50%). Health care workers do not appear to complete ADs at a rate any higher than the general population. Thus, education may be necessary, but alone it appears insufficient to increase use of ADs. Frequent family discussions occur among health care providers and their families. Such discussions may be an important outcome in their own right.
Http Dx Doi Org 10 1080 10401334 2013 827979, Oct 1, 2013
Clinical teaching has moved from the bedside to conference rooms; many reasons are described for ... more Clinical teaching has moved from the bedside to conference rooms; many reasons are described for this shift. Yet, essential clinical skills, professionalism, and humanistic patient interactions are best taught at the bedside. Clinical teaching has moved from the bedside to conference rooms; many reasons are described for this decline. This study explored perceptions of teachers and learners on the value of bedside teaching and the humanistic dimensions of bedside interactions that make it imperative to shift clinical teaching back to the bedside. Focus group methodology was used to explore teacher and learner opinions. Four teacher groups consisted of (a) Chief Residents, (b) Residency Program Directors, (c) skilled bedside teachers, and (d) a convenience group of other Department of Medicine faculty at Boston University School of Medicine. Six learner groups consisted 2 each of 3rd-year students, PGY1 medicine residents, and PGY2 medicine residents. Each discussion lasted 60 to 90 minutes. Sessions were audiotaped, transcribed, and analyzed using qualitative methods. Teachers and learners shared several opinions on bedside teaching, particularly around humanistic aspects of bedside interactions. The key themes that emerged included (a) patient involvement in discussions, (b) teachers as role models of humanism, (c) preserving learner autonomy, (d) direct observation and feedback of learners at the bedside, (e) interactions with challenging patients, and (e) admitting limitations. Within these themes, participants noted some behaviors best avoided at the bedside. Teachers and learners regard the bedside as a valuable venue in which to learn core values of medicine. They proposed many strategies to preserve these humanistic values and improve bedside teaching. These strategies are essential for true patient-centered care.
Academic Medicine, 2016
In this article, the authors reexamine the Ambulatory Diagnostic and Treatment Center (ADTC) mode... more In this article, the authors reexamine the Ambulatory Diagnostic and Treatment Center (ADTC) model, which uniquely combines the education of trainees with the care of referred patients at one Veterans Affairs medical center. As an ambulatory clinic with an inpatient mind-set, the ADTC uses a series of closely spaced outpatient appointments that are longer than typical ambulatory visits, offering a VIP-level of evaluation with the patient-centered goal of expedited diagnosis and treatment. Faculty triage patients by weighing factors such as urgency, educational value, complexity, and instability of diseases in conjunction with the resources, availability, and appropriateness of other services within the medical center.The ADTC's unique focus on the education of trainees in comparison with other clinical rotations is evident in the ratio of learning to patient care. This intensive training environment expects postgraduate year 2 and 3 internal medicine residents and fourth-year medical students to read, reflect, and review literature daily. This mix of education and care delivery is ripe for reexploration in light of recent calls for curriculum reform amidst headlines exposing delays in veterans' access to care.A low-volume, high-intensity clinic like the ADTC can augment the clinical services provided by a busy primary care and subspecialty workforce without losing its emphasis on education. Other academic health centers can learn from this model and adapt its structure in settings where accountable care organizations and education meet.
Academic Medicine Journal of the Association of American Medical Colleges, Oct 1, 2002
The morbidity and mortality conference (M&amp... more The morbidity and mortality conference (M&MC) appears to have sprung from the efforts of physicians to improve practice through the examination of medical errors and bad outcomes. The modern M&MC has had limited examination (and almost none outside surgery and anesthesia), but may be straying from the precepts from which it evolved. Learning from one's errors is important, but confronting them is difficult and is particularly delicate when done in conference. If the effort is successful, it can serve as a model. If unsuccessful, it can instead convey the lesson that attempting to learn from error is at best unproductive and at worst unpleasant. Thus, the M&MC is a double-edged sword, and particular attention should be given to the way that it is conducted. The authors review the historical roots and current literature on the M&MC, discusses relevant literature on medical error, and offers a definition, guiding principles, and a set of guidelines for a modern internal medicine M&MC. The ideas are presented not as a blueprint, but rather to stimulate a debate on the merits of establishing a framework for a working model, in order to refocus on the tradition of self-analysis and critical thinking in a manner that is productive for all participants.
Nihon Naika Gakkai Zasshi, 2008
Journal of women's health (2002), 2015
In 2004, the CDC and the American Cancer Society (ACS) published performance guidelines recommend... more In 2004, the CDC and the American Cancer Society (ACS) published performance guidelines recommending a validated method of clinical breast exams (CBE) using the vertical strips method (VSM) along with other key exam components. We examined the use of the VSM by academic medicine physicians and identified predictor variables for its adoption. Clinician educators in the Society of General Internal Medicine (SGIM) and physicians in the Society of Teachers of Family Medicine (STFM) were administered web-based surveys on CBE practices in 2009. A total of 1,772 (42%) physicians responded. Only 40% of respondents reported using the VSM, compared with 53% using the circular search method. Variables and their odds ratios (ORs) associated with an increase adoption of the VSM were having a primary teaching hospital affiliation (OR 1.4 [1.1, 1.9]), having taken a course on breast health or breast cancer in the past 5 years (OR 1.5 [1.1, 2.0]), and having completed residency in the past 5 years ...
Family medicine, 2010
Community health centers are facing a shortage of primary care physicians at a time when governme... more Community health centers are facing a shortage of primary care physicians at a time when government plans have called for an expansion of community health center programs. To succeed with this expansion, community health centers require additional well-trained physician leadership. Our objective was to ascertain how medical directors obtain leadership skills in an attempt to identify the best methods and venues for providing future leadership training programs. Using recorded interviews and focus group data with community health center medical directors, we identified patterns and themes through cross-case content analysis to determine leadership training needs in underserved settings. Medical directors often enter positions unprepared and can quickly become frustrated by an inability to make system improvements. Medical directors seek multiple ways to obtain the leadership skills necessary, including conferences, peer networking, mentorship, and formal degree training. Many directo...
Journal of the National Medical Association, 2006
To describe black residents' perceptions of the impact of race on medical training. Open-ende... more To describe black residents' perceptions of the impact of race on medical training. Open-ended interviews were conducted of black physicians in postgraduate year 22 who had graduated from U.S. medical schools and were enrolled in residency programs at one medical school. Using Grounded Theory tenets of qualitative research, data was culled for common themes through repeated readings; later, participants commented on themes from earlier interviews. Of 19 participants 10 were male, distributed evenly among medical and surgical fields. Four major themes emerged from the narratives: discrimination, differing expectations, social isolation and consequences. Participants' sense of being a highly visible minority permeated each theme. Overt discrimination was rare. Participants perceived blacks to be punished more harshly for the same transgression and expected to perform at lower levels than white counterparts. Participants' suspicion of racism as a motivation for individual a...
Journal of the American Geriatrics Society, 1992
To examine the relationship between exogenous estrogen use and risk of clinically diagnosed urina... more To examine the relationship between exogenous estrogen use and risk of clinically diagnosed urinary tract infection (UTI) in older women. A case-control study. Two hundred seventy-six general practices. Cases (n = 3,616) were women, age 50-69 years, with a first recorded UTI in the calendar years 1989 or 1990. Controls (n = 19,162) were matched for age and practice. Clinical diagnosis of UTI. Women using estrogens for greater than or equal to 1 year had an increased risk of being diagnosed with a UTI compared to non-users, crude odds ratio (OR) 1.9 (95% CI 1.5-2.2). All of this excess risk was observed in women with intact uteri, OR 2.1 (CI 1.7-2.7). Hysterectomized women had no increased risk, OR 1.1 (CI 0.8-1.5). Controlling for diabetes, neurologic deficit, atrophic vaginitis, incontinence, and age did not affect the observed associations. Estrogen use is associated with an increased risk of UTI in older women with intact uteri but not in hysterectomized women. This observed diff...
Southern Medical Journal, 1999
Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance ... more Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance of education in the decision to execute an AD, I did this study to determine the rate at which health care workers (a medically educated group) and their families execute ADs. All clinical staff at an urban tertiary care VA medical center were surveyed. Of 730 surveys mailed, 553 (76%) were returned, and 18% of respondents executed an AD. Age was the only variable that predicted execution of an AD. End-of-life medical decision-making discussions with family members were reported frequently (with spouses 74%, parents 50%). Health care workers do not appear to complete ADs at a rate any higher than the general population. Thus, education may be necessary, but alone it appears insufficient to increase use of ADs. Frequent family discussions occur among health care providers and their families. Such discussions may be an important outcome in their own right.
Medical Teacher, 2007
Little has been written on the art of using a board in clinical teaching. The technological devel... more Little has been written on the art of using a board in clinical teaching. The technological development of the white board appears to have coincided with that of the laptop computer and accompanying LCD projector, so that fewer and fewer teaching sessions appear to utilize the board as an efficient teaching tool. I have observed this most commonly among younger faculty who are most comfortable with technology and who may lack training and experience with a blank board. This paper offers suggestions on using the board in clinical teaching in order to enhance the educational process through better engagement of the learners.
Medical Education Online, 2006
Purpose: To develop a tool to assess the team leadership skills of internal medicine residents. M... more Purpose: To develop a tool to assess the team leadership skills of internal medicine residents. Method: A 27-item pilot instrument developed by two authors was distributed to interns on ward and intensive care unit teams at the end of rotations from a single institution's internal medicine residency program. These items were factor analyzed and reduced to a seven-item resident leadership scale (RLS). Validity of the instrument was assessed by comparing the rating on the RLS to scores on a validated measure of teaching skills provided at the same time and by the program director's global rating of team leadership skill for each resident at the completion of data collection. Results: The three principal components from the factor analysis explained 82 percent of the variance. By introspection we reduced the scale to the final 7-item RLS that had a Cronbach alpha reliability estimate of 0.95. 490 ratings on 134 individual residents were available for analysis. The RLS scores correlated highly with both the validated measure of teaching skill and the program director's ratings. Conclusion: The RLS has robust psychometric properties. It may provide a useful tool for a broader assessment of trainee skill if validated in other settings.
Journal of General Internal Medicine, 1991
To determine whether current fellowships in general internal medicine (FGIM) meet the perceived n... more To determine whether current fellowships in general internal medicine (FGIM) meet the perceived needs and objectives of physicians entering careers in academic internal medicine. A modified Delphi method yielded the 18 curricular elements included in the mailed survey. Participants outlined both actual and ideal fellowship experiences by rating the degree of emphasis of each curricular element on a Likert scale. Respondents then prioritized elements by rank-ordering them on perceived importance. Current job descriptions and opinions on related issues in FGIM were collected. Potential fellows, current fellows, and recent graduates were surveyed. Individuals were identified through the Society of General Internal Medicine associates' mailing list and solicitation of program directors. Nonfellow associates served as the proxy group for potential fellows. 579 surveys were mailed; 348 (60%) responses were received, of which 288 (50%) were suitable for analysis. Of all respondents, 38% were current fellows and 40% were recent graduates. When asked to prioritize educational needs during fellowship training, respondents ranked research methodology, ambulatory medicine, critical review of the literature, epidemiology, biostatistics, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curriculum as the top ten. Only minor deviations in rank order were found between graduates and nongraduates. Mean Likert scale scores for degree of emphasis of each curricular element in graduates' actual fellowships were compared with mean scores for graduates' ideal fellowship descriptions. High-priority elements that were perceived as adequately emphasized included research methodology, critical analysis of the literature, epidemiology, and biostatistics. High-priority elements that were perceived as inadequately emphasized included ambulatory medicine, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curricula. FGIM largely meet the expectations of their fellows for preparation for research responsibilities. However, several curricular elements concerned with preparation for future clinical and teaching responsibilities are perceived by graduates as underemphasized. These areas deserve increased emphasis during fellowship training to better prepare fellows for their future roles in academic general internal medicine.