From the Editor

In her editorial, Sullivan likens the community's acceptance of the misalignment between physician production and the nation's health care needs to a “tragedy of the commons” (p. 1).

Perspectives

Grimm and colleagues discuss misrepresentation in the residency application process and National Resident Matching Program policies for postinterview communications, and encourage the community to move toward sensible regulations (p. 7).

Schrager and Sadowski suggest a “to-do list” as a strategy for increasing scholarly productivity (p. 10).

Using a question-and-answer format, Lawson and Kalet discuss the legal framework for a decision to conduct an administrative psychiatric evaluation on a

ABSTRACT

Background

Efforts to improve diabetes care in residency programs are ongoing and in the midst of continuity clinic redesign at many institutions. While there appears to be a link between resident continuity and improvement in glycemic control for diabetic patients, it is uncertain whether clinic structure affects quality measures and patient outcomes.

Methods

This multi-institutional, cross-sectional study included 12 internal medicine programs. Three outcomes (glycemic control, blood pressure control, and achievement of target low-density lipoprotein [LDL]) and 2 process measures (A1C and LDL measurement) were reported for diabetic patients. Traditional, block, and combination clinic models were compared using analysis of covariance (ANCOVA). Analysis was adjusted for continuity, utilization, workload, and panel size.

Results

No significant differences were found in glycemic control across clinic models (P = .06). The percentage of diabetic patients with LDL < 100 mg/dL was 60% in block, compared to 54.9% and 55% in traditional and combination models (P = .006). The percentage of diabetic patients with blood pressure < 130/80 mmHg was 48.4% in block, compared to 36.7% and 36.9% in other models (P < .001). The percentage of diabetic patients with HbA1C measured was 92.1% in block compared to 75.2% and 82.1% in other models (P < .001). Also, the percentage of diabetic patients with LDL measured was significantly different across all groups, with 91.2% in traditional, 70.4% in combination, and 83.3% in block model programs (P < .001).

Conclusions

While high scores on diabetic quality measures are achievable in any clinic model, the block model design was associated with better performance.

ABSTRACT

Background

The importance of continuity of care in training is widely recognized; however, a broad-spectrum assessment across all specialties has not been performed.

Objective

We assessed the continuity of care provided by trainees, following patient consultations in the emergency department (ED) across all specialties at a large pediatric tertiary care center.

Methods

Medical records were reviewed to identify patients seen in consultation by a resident or fellow trainee in the ED over a 1-year period, and to determine if the patient followed up with the same trainee for the same condition during the next 6 months.

Results

Resident and fellow trainees from 33 specialties participated in 3400 ED consultations. Approximately 50% (1718 of 3400) of the patients seen in consultation by a trainee in the ED followed up with the same specialty within 6 months, but only 4.1% (70 of 1718) followed up with the same trainee for the same condition. Trainee continuity of care ranged from 0% to 21% among specialties, where specialties with resident clinics (14.4%) have a greater continuity of care than specialties without resident clinics (2.7%, P < .001). Continuity of care did not differ between fellows (4.2%) and residents (4.0%, P = .87), but did differ between postgraduate years for residents (P < .001).

Conclusions

Trainee continuity of care for ED consultations was low across all specialties and levels of training. If continuity of care is important for patient well-being and trainee education, efforts to improve continuity for trainees must be undertaken.

ABSTRACT

Background

Since the late 1980s, resident physicians have spent increasing amounts of time on electronic health record (EHR) data entry and retrieval. Objective longitudinal data measuring time spent on the EHR are lacking.

Objective

We sought to quantify the time actually spent using the EHR by all first-year internal medicine residents in a single program (N = 41).

Methods

Active EHR usage data were collected from the audit logs for May, July, and October 2014 and January 2015. Per recommendations from our EHR vendor (Cerner Corporation), active EHR usage time was defined as more than 15 keystrokes, or 3 mouse clicks, or 1700 “mouse miles” per minute. Active EHR usage time was tallied for each patient chart viewed each day and termed an electronic patient record encounter (EPRE).

Results

In 4 months, 41 interns accumulated 18 322 hours of active EHR usage in more than 33 733 EPREs. Each intern spent on average 112 hours per month on 206 EPREs. Interns spent more time in July compared to January (41 minutes versus 30 minutes per EPRE, P < .001). Time spent on the EHR in January echoed that of the previous May (30 minutes versus 29 minutes, P = .40).

Conclusions

First-year residents spent a significant amount of time actively using the EHR, achieving maximal proficiency on or before January of the academic year. Decreased time spent on the EHR may reflect greater familiarity with the EHR, growing EHR efficiencies, or other factors.

The Journal of Graduate Medical Education is deeply grateful to the individuals who served as reviewers and provided critiques and helpful suggestions to authors for the 4 issues published in 2015. Reviewers shown bolded reviewed a significant number of articles, and the Journal greatly appreciates the contribution of their time, energy, and expertise.

Eva Aagaard, MD

Ralitsa Akins, MD, PhD

Ronald Amedee, MD

Gowri Anandarajah, MD

Douglas Ander, MD

Kathryn Andolsek, MD, MPH

Mary Andrews, MD

Tanya Anim, MD

Felix Ankel, MD

Vineet Arora, MD

Carol Aschenbrener, MD

Miriam Bar-on, MD

Carol Bates, MD

Gary Beck,