Editorials

An editorial by Editor-in-Chief Gail Sullivan emphasizes the value of evidence-based approaches to allow decisions about residents' and fellows' learning and professional development to be rooted in evidence. Its companion offers concrete guidance on the validity in assessment instruments used in medical education research (p. 119).

Perspectives

In a Perspective piece, Roberts and Williams highlight the issue of learners with performance problems who are neither dismissed nor truly remediated and who persist despite potentially dangerous behaviors (p. 127).

Original Research

Bazemore et al explore the association between graduate medical education in a family medicine program's long-standing

Abstract

Background

Recent efforts to increase insurance coverage have revealed limits in primary care capacity, in part due to physician maldistribution. Of interest to policymakers and educators is the impact of nontraditional curricula, including global health education, on eventual physician location. We sought to measure the association between graduate medical education in global health and subsequent care of the underserved in the United States.

Methods

In 2005, we surveyed 137 graduates of a family medicine program with one of the country's longest-running international health tracks (IHTs). We compared graduates of the IHT, those in the traditional residency track, and graduates prior to IHT implementation, assessing the anticipated and actual involvement in care of rural and other underserved populations, physician characteristics, and practice location and practice population.

Results

IHT participants were more likely to practice abroad and care for the underserved in the United States in the first 5 years following residency than non-IHT peers. Their current practices were more likely to be in underserved settings and they had higher percentages of uninsured and non–English-speaking patients. Comparisons between pre-IHT and post-IHT inception showed that in the first 5 years following residency, post-IHT graduates were more likely to care for the underserved and practice in rural areas and were likely to offer volunteer community health care services but were not more likely to practice abroad or to be in an academic practice.

Conclusions

Presence of an IHT was associated with increased care of underserved populations. After the institution of an IHT track, this association was seen among IHT participants and nonparticipants and was not associated with increased long-term service abroad.

Abstract

Background

Starting in the 1960s, studies have suggested that peer evaluation could provide unique insights into the performance of residents in training. However, reports of resident resistance to peer evaluation because of confidentiality issues and the possible impact on their working relationships raised concerns about the acceptability and utility of peer evaluation in graduate medical education. The literature suggests that peers are able to reliably assess communication, interpersonal skills, and professionalism and provide input that may differ from faculty evaluations. This study assessed the attitudes of internal medicine residents 1 year after the implementation of a peer-evaluation system.

Methods

During the 2005–2006 academic year, we conducted an anonymous survey of the 168 residents in the Internal Medicine Residency Program at the Mayo Clinic, Rochester, Minnesota. Contingency table analysis was used to compare the response patterns of the groups.

Results

The response rate was 61% (103/168 residents) and it did not differ by year of training. Most residents (74/103; 72%) felt that peers could provide valuable feedback. Eighty percent of residents (82/103) felt the feedback was important for their professional development and 84% (86/102) agreed that peers observe behaviors not seen by attending faculty.

Conclusions

The results of this study suggest that internal medicine residents provide unique assessment of their peers and provide feedback they consider important for their professional development. More importantly, the results support the role of peer evaluation in the assessment of the competencies of professionalism and interpersonal and communication skills.

Abstract

Background

Recent focus on resident work hours has challenged residency programs to modify their curricula to meet established duty hour restrictions and fulfill their mission to develop the next generation of clinicians. Simultaneously, health care systems strive to deliver efficient, high-quality care to patients and families. The primary goal of this observational study was to use a data-driven approach to eliminate examples of waste and variation identified in resident rounding using Lean Six Sigma methodology. A secondary goal was to improve the efficiency of the rounding process, as measured by the reduction in nonvalue-added time.

Methods

We used the “DMAIC” methodology: define, measure, analyze, improve, and control. Pediatric and family medicine residents rotating on the pediatric hospitalist team participated in the observation phase. Residents, nurses, hospitalists, and parents of patients completed surveys to gauge their attitudes toward rounds. The Mann-Whitney test was used to test for differences in the median times measured during the preimprovement and postimprovement phases, and the Student t test was used for comparison of survey data.

Results and Discussion

Collaborative, family-centered rounding with elimination of the “prerounding” process, as well as standard work instructions and pacing the process to meet customer demand (takt time), were implemented. Nonvalue-added time per patient was reduced by 64% (P = .005). Survey data suggested that team members preferred the collaborative, family-centered approach to the traditional model of rounding.

Conclusions

Lean Six Sigma provides tools, a philosophy, and a structured, data-driven approach to address a problem. In our case this facilitated an effort to adhere to duty hour restrictions while promoting education and quality care. Such approaches will become increasingly useful as health care delivery and education continue to transform.

The traditional marriage between teaching hospitals and residents pivots on a central prenuptial agreement: residents offer their hospitals round-the-clock patient care, and, in exchange, hospitals provide an experiential learning modality. This long-held covenant may require an update due to 3 significant changes: the increased spotlight on protecting resident education from excessive service demands; the development of hospital medicine as a specialty; and the need to provide more experiential learning in ambulatory care settings for primary care programs, including family medicine.

The rapid growth of hospitalist care—84% of all teaching hospitals in the United States have at least 3 hospitalists1