A patient follow-up intervention to improve medical decision making at an internal medicine residency program

Leela Chockalingam; Angela Keniston; Lauren McBeth; Marina Mutter

doi:10.1515/dx-2023-0135

Article

A patient follow-up intervention to improve medical decision making at an internal medicine residency program

Leela Chockalingam , Angela Keniston , Lauren McBeth and Marina Mutter

Published/Copyright: February 6, 2024

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From the journal Diagnosis Volume 11 Issue 2

Abstract

Objectives

Practice-based learning and improvement (PBLI) is an ACGME (Accreditation Council for Graduate Medical Education) core competency. Learning and reflecting on patients through follow-up is one method to help achieve this competency. We therefore designed a study evaluating a structured patient follow-up intervention for senior internal medicine (IM) residents at the University of Colorado Hospital (UCH).

Methods

Trainees completed structured reflections after performing chart review of prior patients during protected educational time. Two-month follow-up surveys evaluated the exercise’s potential influence on clinical and reflective practices.

Results

Forty out of 108 (37 %) eligible residents participated in the exercise. Despite 62.5 % of participants lacking specific questions about patient outcomes before chart review, 81.2 % found the exercise at least moderately helpful. 48.4 % of participants believed that the review would change their practice, and 60.9 % felt it reinforced their existing clinical practices. In our qualitative data, residents learned lessons related to challenging clinical decisions, improving transitions of care, the significance of early goals of care conversations, and diagnostic errors/strategies.

Conclusions

Our results indicate that IM residents found a structured patient follow-up intervention educational, even when they lacked specific patient outcomes questions. Our results underscore the importance of structured self-reflection in the continuous learning process of trainees and suggest the benefit of dedicated educational time for this process.

Keywords: clinical reasoning; medical education; diagnostic errors; practice-based learning and improvement; qualitative research

Corresponding author: Leela Chockalingam, MD, Department of Hospital Medicine, University of Colorado School of Medicine, 12401 East 17th Avenue, Aurora, CO, 80045, USA, E-mail: leela.chockalingam@cuanschutz.edu

Research ethics: The local Institutional Review Board deemed the study exempt from review.
Informed consent: Informed consent was obtained from all individuals included in this study.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Research funding: None declared.
Data availability: The raw data can be obtained on request from the corresponding author.

References

1. ACGME. ACGME program requirements for graduate medical education in internal medicine; 2020. Available from: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/140_InternalMedicine_2020.pdf?ver=2020-06-29-161610-040.Search in Google Scholar

2. Murthy, VK, O’Brien, B, Dhaliwal, G. An inquiry into the early careers of master clinicians. J Graduate Med Educ 2018;10:500–6. https://doi.org/10.4300/jgme-d-18-00208.1.Search in Google Scholar

3. Ball, JR, Balogh, E. Improving diagnosis in health care: highlights of a report from the National Academies of Sciences, Engineering, and Medicine. Ann Intern Med 2016;164:59–61. https://doi.org/10.7326/m15-2256.Search in Google Scholar

4. Nothnagle, M, Anandarajah, G, Goldman, RE, Reis, S. Struggling to be self-directed: residents’ paradoxical beliefs about learning. Acad Med J Assoc Am Med Coll 2011;86:1539–44. https://doi.org/10.1097/acm.0b013e3182359476.Search in Google Scholar

5. Graber, ML, Franklin, N, Gordon, R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493–99. https://doi.org/10.1001/archinte.165.13.1493.Search in Google Scholar PubMed

6. Mele, AR. Real self-deception. Behav Brain Sci 1997;20:91–102. https://doi.org/10.1017/s0140525x97000034.Search in Google Scholar PubMed

7. Kruger, J, Dunning, D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol 1999;77:1121–34. https://doi.org/10.1037//0022-3514.77.6.1121.Search in Google Scholar PubMed

8. Krueger, J, Mueller, RA. Unskilled, unaware, or both? The better-than-average heuristic and statistical regression predict errors in estimates of own performance. J Pers Soc Psychol 2002;82:180–88. https://doi.org/10.1037//0022-3514.82.2.180.Search in Google Scholar

9. Friedman, CP, Gatti, GG, Franz, TM, Murphy, GC, Wolf, FM, Heckerling, PS, et al.. Do physicians know when their diagnoses are correct? Implications for decision support and error reduction. J Gen Intern Med 2005;20:334–39. https://doi.org/10.1111/j.1525-1497.2005.30145.x.Search in Google Scholar PubMed PubMed Central

10. Narayana, S, Rajkomar, A, Harrison, JD, Valencia, V, Dhaliwal, G, Ranji, SR. What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. J Graduate Med Educ 2017;9:627–33. https://doi.org/10.4300/jgme-d-16-00846.1.Search in Google Scholar

11. Lane, KP, Chia, C, Lessing, JN, Limes, J, Mathews, B, Schaefer, J, et al.. Improving resident feedback on diagnostic reasoning after handovers: the LOOP project. J Hosp Med 2019;14:622–25. https://doi.org/10.12788/jhm.3262.Search in Google Scholar PubMed

12. Bowen, JL, Ilgen, JS, Irby, DM, Ten Cate, O, O’Brien, BC. “You have to know the end of the story”: motivations to follow up after transitions of clinical responsibility. Acad Med J Assoc Am Med Coll 2017;92:S48–54. https://doi.org/10.1097/acm.0000000000001919.Search in Google Scholar

13. Bowen, JL, O’Brien, BC, Ilgen, JS, Irby, DM, Ten Cate, O. Chart stalking, list making, and physicians’ efforts to track patients’ outcomes after transitioning responsibility. Med Educ 2018;52:404–13. https://doi.org/10.1111/medu.13509.Search in Google Scholar PubMed

14. Harris, PA, Taylor, R, Thielke, R, Payne, J, Gonzalez, N, Conde, JG. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81. https://doi.org/10.1016/j.jbi.2008.08.010.Search in Google Scholar PubMed PubMed Central

15. Hsieh, HF, Shannon, SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277–88. https://doi.org/10.1177/1049732305276687.Search in Google Scholar PubMed

16. Lim, H, Raffel, KE, Harrison, JD, Kohlwes, RJ, Dhaliwal, G, Narayana, S. Decisions in the dark: an educational intervention to promote reflection and feedback on night float rotations. J Gen Intern Med 2020;35:3363–67. https://doi.org/10.1007/s11606-020-05913-z.Search in Google Scholar PubMed PubMed Central

17. Smith, KA. To keep an incessant watch. Acad Emerg Med 2011;18:545–48. https://doi.org/10.1111/j.1553-2712.2011.01052.x.Search in Google Scholar PubMed

18. Dhand, A. Right brain: the case library as a tool to enhance clinical observation. Neurology 2012;78:512–13. https://doi.org/10.1212/wnl.0b013e318246d6c8.Search in Google Scholar PubMed

19. Brisson, GE, Tyler, PD. Medical student use of electronic health records to track former patients. JAMA Intern Med 2016;176:1395–97. https://doi.org/10.1001/jamainternmed.2016.3878.Search in Google Scholar PubMed

20. Rosenbluth, G, Tong, MS, Condor Montes, SY, Boscardin, C. Trainee and program director perspectives on meaningful patient attribution and clinical outcomes data. J Grad Med Educ 2020;12:295–302. https://doi.org/10.4300/jgme-d-19-00730.1.Search in Google Scholar PubMed PubMed Central

21. Mutter, M, Kyle, JR, Yecies, E, Hamm, M, DiNardo, D. Use of chart-stimulated recall to explore uncertainty in medical decision-making among senior internal medicine residents. J Gen Intern Med 2022;37:3114–20. https://doi.org/10.1007/s11606-022-07396-6.Search in Google Scholar PubMed PubMed Central

22. Lee, YW, Kudva, KG, Soh, M, Chew, QH, Sim, K. Inter-relationships between burnout, personality and coping features in residents within an ACGME-I Accredited Psychiatry Residency Program. Asia Pac Psychiatr 2022;14:e12413. https://doi.org/10.1111/appy.12413.Search in Google Scholar PubMed

23. Haber, MA, Gaviola, GC, Mann, JR, Kim, J, Malone, FE, Matalon, SA, et al.. Reducing burnout among radiology trainees: a novel residency retreat curriculum to improve camaraderie and personal wellness – 3 strategies for success. Curr Probl Diagn Radiol 2020;49:89–95. https://doi.org/10.1067/j.cpradiol.2019.09.001.Search in Google Scholar PubMed

24. Pan, JY, Yong, FSH, Chua, TE, Chen, HY. Tele-Balint under the microscope: what really happens in Tele-Balint groups? Int J Psychiatr Med 2023;58:231–48. https://doi.org/10.1177/00912174221092505.Search in Google Scholar PubMed

25. Singh, H, Khanna, A, Spitzmueller, C, Meyer, AND. Recommendations for using the Revised Safer Dx Instrument to help measure and improve diagnostic safety. Diagnosis 2019;6:315–23. https://doi.org/10.1515/dx-2019-0012.Search in Google Scholar PubMed

26. Brisson, GE, Neely, KJ, Tyler, PD, Barnard, C. Should medical students track former patients in the electronic health record? An emerging ethical conflict. Acad Med J Assoc Am Med Coll 2015;90:1020–24. https://doi.org/10.1097/acm.0000000000000633.Search in Google Scholar

27. Yarahuan, JKW, Lo, HY, Bass, L, Wright, J, Hess, LM. Design, usability, and acceptability of a needs-based, automated dashboard to provide individualized patient-care data to pediatric residents. Appl Clin Inf 2022;13:380–90. https://doi.org/10.1055/s-0042-1744388.Search in Google Scholar PubMed PubMed Central

28. Heath, JK, Alvarado, ME, Clancy, CB, Barton, TD, Kogan, JR, Dine, CJ. The context of “confidence”: analyzing the term confidence in resident evaluations. J Gen Intern Med 2022;37:2187–93. https://doi.org/10.1007/s11606-022-07535-z.Search in Google Scholar PubMed PubMed Central

29. Chatterjee, D, Jacob, GA, Varvayanis, SS, Wefes, I, Chalkley, R, Nogueira, AT, et al.. Career self-efficacy disparities in underrepresented biomedical scientist trainees. PLoS One 2023;18:e0280608. https://doi.org/10.1371/journal.pone.0280608.Search in Google Scholar PubMed PubMed Central

Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/dx-2023-0135).

Received: 2023-10-04

Accepted: 2024-01-11

Published Online: 2024-02-06

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Supplementary Material

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Keywords for this article

clinical reasoning; medical education; diagnostic errors; practice-based learning and improvement; qualitative research