Andrew J Halvorsen

Mayo Foundation for Medical Education and Research, Rochester, MI, United States

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Publications (34)143.4 Total impact

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    ABSTRACT: Background Despite its importance, little is known about internal medicine (IM) residents’ ability to assess and communicate a patient’s overnight risk during the resident-to-resident handoff. Objective To evaluate IM residents’ ability to identify patients at risk for clinical deterioration using the Patient Acuity Rating (PAR) tool (scored on a 1–7 symmetric scale; 1=“Extremely unlikely”, 7=“Extremely likely”), and to measure how well IM residents conveyed a patient’s potential for clinical deterioration during day-to-night handoff. Design and Participants Observational cohort study of 46 postgraduate year 1 (PGY-1) and 32 postgraduate year 3 (PGY-3) internal medicine residents rotating on one of four general medicine services from October 2013 through January 2014. Main Measures Primary outcomes were (1) level of agreement between resident handoff giver and receiver regarding patients’ clinical risk and (2) accuracy of resident-assigned PAR score in predicting a patient’s risk of clinical deterioration over the subsequent 24 hours. Key Results Analysis of PGY-1 giver–receiver handoff agreement revealed an intraclass correlation coefficient (ICC) (95 % CI) of 0.51 (0.45–0.56), while PGY-3 giver–receiver agreement yielded an ICC (95 % CI) of 0.42 (0.36–0.47). Based on 865 ratings of 378 patients, PGY-1 handoff giver PAR scores of 5 and 6+ were significantly associated with increased odds of clinical deterioration within 24 hours (aOR = 6.5 and 12.4; P = 0.03 and 0.005, respectively). For the 1,170 PAR ratings of 438 patients assigned by PGY-3 handoff givers, PAR scores of 4, 5, and 6+ were significantly associated with increased odds of an event within 24 hours (aORs = 6.0, 9.6, and 18.1; P = 0.03, 0.01, and 0.0008, respectively). Conclusions The PAR is a useful tool to quantify IM residents’ judgment of patient stability, and may be particularly valuable during resident handoff, given that the level of agreement between giver and receiver regarding patient risk is only fair.
    Journal of General Internal Medicine 12/2014; · 3.42 Impact Factor
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    ABSTRACT: With the advent of compact ultrasound (US) devices, it is easier for physicians to enhance their physical examinations through the use of US. However, although this new tool is widely available, few internal medicine physicians have US training. This study sought to understand physicians' baseline knowledge and skill, provide education in US principles, and demonstrate that proper use of compact US devices is a skill that can be quickly learned.
    Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 06/2014; 33(6):1005-11. · 1.53 Impact Factor
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    ABSTRACT: The transition from medical student to intern may cause stress and burnout in new interns and the delivery of suboptimal patient care. Despite a formal set of subinternship curriculum guidelines, program directors have expressed concern regarding the skill set of new interns and the lack of standardization in that skill set among interns from different medical schools. To address these issues, the Accreditation Council for Graduate Medical Education's Next Accreditation System focuses on the development of a competency-based education continuum spanning undergraduate, graduate, and continuing medical education. In 2010, the Clerkship Directors in Internal Medicine subinternship task force, in collaboration with the Association of Program Directors in Internal Medicine survey committee, surveyed internal medicine residency program directors to determine which competencies or skills they expected from new medical school graduates. The authors summarized the results using categories of interest. In both an item rank list and free-text responses, program directors were nearly uniform in ranking the skills they deemed most important for new interns-organization and time management and prioritization skills; effective communication skills; basic clinical skills; and knowing when to ask for assistance. Stakeholders should use the results of this survey as they develop a milestone-based curriculum for the fourth year of medical school and for the internal medicine subinternship. By doing so, they should develop a standardized set of skills that meet program directors' expectations, reduce the stress of transitions across the educational continuum, and improve the quality of patient care.
    Academic medicine: journal of the Association of American Medical Colleges 01/2014; · 2.34 Impact Factor
  • The American Journal of Medicine. 01/2014;
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    ABSTRACT: Annual data reporting for residency programs in the Next Accreditation System (NAS) includes new components, including changes in the annual resident survey. Program directors from multiple specialties have expressed concerns regarding the survey related to residents' understanding of the questions, accuracy of the data, and use of the results by the Accreditation Council for Graduate Medical Education (ACGME). We surveyed internal medicine program directors to ascertain their opinions of the ACGME resident survey in order to better inform policymakers as residency programs implement the NAS. 272 program directors responded. Most program directors disagreed with the changes in the resident survey, did not believe there was sufficient transparency in its use, and believe they should receive aggregate responses from their residents. A majority of program directors used resident survey data to secure program resources. Program directors do not seem to find it overly burdensome to have residents complete the survey, with 41% finding it "easy" to assure completion. The 2013 changes in the annual resident survey as part of the NAS were not generally accepted by program directors in internal medicine. Nonetheless, program directors continue to use survey results to support the program. How the survey results will be incorporated into accreditation decisions is a significant concern among internal medicine program directors.
    The American journal of medicine 12/2013; · 5.30 Impact Factor
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    ABSTRACT: Valid teamwork assessment is imperative to determine physician competency and optimize patient outcomes. We systematically reviewed published instruments assessing teamwork in undergraduate, graduate, and continuing medical education in general internal medicine and all medical subspecialties. We searched MEDLINE, MEDLINE In-process, CINAHL and PsycINFO from January 1979 through October 2012, references of included articles, and abstracts from four professional meetings. Two content experts were queried for additional studies. Included studies described quantitative tools measuring teamwork among medical students, residents, fellows, and practicing physicians on single or multi-professional (interprofessional) teams. Instrument validity and study quality were extracted using established frameworks with existing validity evidence. Two authors independently abstracted 30 % of articles and agreement was calculated. Of 12,922 citations, 178 articles describing 73 unique teamwork assessment tools met inclusion criteria. Interrater agreement was intraclass correlation coefficient 0.73 (95 % CI 0.63-0.81). Studies involved practicing physicians (142, 80 %), residents/fellows (70, 39 %), and medical students (11, 6 %). The majority (152, 85 %) assessed interprofessional teams. Studies were conducted in inpatient (77, 43 %), outpatient (42, 24 %), simulation (37, 21 %), and classroom (13, 7 %) settings. Validity evidence for the 73 tools included content (54, 74 %), internal structure (51, 70 %), relationships to other variables (25, 34 %), and response process (12, 16 %). Attitudes and opinions were the most frequently assessed outcomes. Relationships between teamwork scores and patient outcomes were directly examined for 13 (18 %) of tools. Scores from the Safety Attitudes Questionnaire and Team Climate Inventory have substantial validity evidence and have been associated with improved patient outcomes. Review is limited to quantitative assessments of teamwork in internal medicine. There is strong validity evidence for several published tools assessing teamwork in internal medicine. However, few teamwork assessments have been directly linked to patient outcomes.
    Journal of General Internal Medicine 12/2013; · 3.42 Impact Factor
  • The American journal of medicine 10/2013; 126(10):931-6. · 5.30 Impact Factor
  • Journal of General Internal Medicine 09/2013; · 3.42 Impact Factor
  • The American journal of medicine 09/2013; 126(9):838-42. · 5.30 Impact Factor
  • The American journal of medicine 06/2013; 126(6):550-556. · 5.30 Impact Factor
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    ABSTRACT: Evidence-based practice in education requires high-quality evidence, and many in the medical education community have called for an improvement in the methodological quality of education research. Our aim was to use a valid measure of medical education research quality to highlight the methodological quality of research publications and provide an overview of the recent internal medicine (IM) residency literature. We searched MEDLINE and PreMEDLINE to identify English-language articles published in the United States and Canada between January 1, 2010, and December 31, 2011, focusing on IM residency education. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI), which has demonstrated reliability and validity. Qualitative articles were excluded. Articles were ranked by quality score, and the top 25% were examined for common themes, and 2 articles within each theme were selected for in-depth presentation. The search identified 731 abstracts of which 223 articles met our inclusion criteria. The mean (±SD) MERSQI score of the 223 studies included in the review was 11.07 (±2.48). Quality scores were highest for data analysis (2.70) and lowest for study design (1.41) and validity (1.29). The themes identified included resident well-being, duty hours and resident workload, career decisions and gender, simulation medicine, and patient-centered outcomes. Our review provides an overview of the IM medical education literature for 2010-2011, highlighting 5 themes of interest to the medical education community. Study design and validity are 2 areas where improvements in methodological quality are needed, and authors should consider these when designing research protocols.
    Journal of graduate medical education. 06/2013; 5(2):203-210.
  • The American journal of medicine 05/2013; · 5.30 Impact Factor
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    ABSTRACT: BACKGROUND: Patient care and medical knowledge are Accreditation Council for Graduate Medical Education (ACGME) core competencies. The correlation between amount of patient contact and knowledge acquisition is not known. OBJECTIVE: To determine if a correlation exists between the number of patient encounters and in-training exam (ITE) scores in internal medicine (IM) and pediatric residents at a large academic medical center. DESIGN: Retrospective cohort study PARTICIPANTS: Resident physicians at Mayo Clinic from July 2006 to June 2010 in IM (318 resident-years) and pediatrics (66 resident-years). METHODS: We tabulated patient encounters through review of clinical notes in an electronic medical record during post graduate year (PGY)-1 and PGY-2. Using linear regression models, we investigated associations between ITE score and number of notes during the previous PGY, adjusted for previous ITE score, gender, medical school origin, and conference attendance. KEY RESULTS: For IM, PGY-2 admission and consult encounters in the hospital and specialty clinics had a positive linear association with ITE-3 % score (β = 0.02; p = 0.004). For IM, PGY-1 conference attendance is positively associated with PGY-2 ITE performance. We did not detect a correlation between PGY-1 patient encounters and subsequent ITE scores for IM or pediatric residents. No association was found between IM PGY-2 ITE score and inpatient, outpatient, or total encounters in the first year of training. Resident continuity clinic and total encounters were not associated with change in PGY-3 ITE score. CONCLUSIONS: We identified a positive association between hospital and subspecialty encounters during the second year of IM training and subsequent ITE score, such that each additional 50 encounters were associated with an increase of 1 % correct in PGY-3 ITE score after controlling for previous ITE performance and continuity clinic encounters. We did not find a correlation for volume of encounters and medical knowledge for IM PGY-1 residents or the pediatric cohort.
    Journal of General Internal Medicine 04/2013; · 3.42 Impact Factor
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    ABSTRACT: BACKGROUND: There have been recent calls for improved internal medicine outpatient training, yet assessment of clinical and educational variables within existing models is lacking. OBJECTIVE: To assess the impact of clinic redesign from a traditional weekly clinic model to a 50/50 outpatient-inpatient model on clinical and educational outcomes. DESIGN: Pre-intervention and post-intervention study intervals, comparing the 2009-2010 and 2010-2011 academic years. PARTICIPANTS: Ninety-six residents in a Primary Care Internal Medicine site of a large academic internal medicine residency program who provide care for > 13,000 patients. INTERVENTION: Continuity clinic redesign from a traditional weekly clinic model to a 50/50 model characterized by 50 % outpatient and 50 % inpatient experiences scheduled in alternating 1 month blocks, with twice weekly continuity clinic during outpatient months and no clinic during inpatient months. MAIN MEASURES: 1) Clinical outcomes (panel size, patient visits, adherence with chronic disease and preventive service guidelines, continuity of care, patient satisfaction, and perceived safety/teamwork in clinic); 2) Educational outcomes (attendance at teaching conference, resident and faculty satisfaction, faculty assessment of resident clinic performance, and residents' perceived preparedness for outpatient management). RESULTS: Redesign was associated with increased mean panel size (120 vs. 137.6; p ≤ 0.001), decreased continuity of care (63 % vs. 48 % from provider perspective; 61 % vs. 51 % from patient perspective; p ≤ 0.001 for both; team continuity was preserved), decreased missed appointments (12.5 % vs. 10.9 %; p ≤ 0.01), improved perceived safety and teamwork (3.6 vs. 4.1 on 5-point scale; p ≤ 0.001), improved mean teaching conference attendance (57.1 vs. 64.4; p ≤ 0.001), improved resident clinic performance (3.6 vs. 3.9 on 5-point scale; p ≤ 0.001), and little change in other outcomes. CONCLUSION: Although this model requires further study in other settings, these results suggest that a 50/50 model may allow residents to manage more patients while enhancing the climate of teamwork and safety in the continuity clinic, compared to traditional models. Future work should explore ways to preserve continuity of care within this model.
    Journal of General Internal Medicine 04/2013; · 3.42 Impact Factor
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    ABSTRACT: BACKGROUND: Physician burnout and distress has been described in national studies of practicing physicians, internal medicine (IM) residents, IM clerkship directors, and medical school deans. However, no comparable national data exist for IM residency program directors. OBJECTIVE: To assess burnout and distress among IM residency program directors, and to evaluate relationships of distress with personal and program characteristics and perceptions regarding implementation and consequences of Accreditation Council for Graduate Medical Education (ACGME) regulations. DESIGN AND PARTICIPANTS: The 2010 Association of Program Directors in Internal Medicine (APDIM) Annual Survey, developed by the APDIM Survey Committee, was sent in August 2010 to the 377 program directors with APDIM membership, representing 99.0 % of the 381 United States categorical IM residency programs. MAIN MEASURES: The 2010 APDIM Annual Survey included validated items on well-being and distress, including questions addressing quality of life, satisfaction with work-life balance, and burnout. Questions addressing personal and program characteristics and perceptions regarding implementation and consequences of ACGME regulations were also included. KEY RESULTS: Of 377 eligible program directors, 282 (74.8 %) completed surveys. Among respondents, 12.4 % and 28.8 % rated their quality of life and satisfaction with work-life balance negatively, respectively. Also, 27.0 % reported emotional exhaustion, 10.4 % reported depersonalization, and 28.7 % reported overall burnout. These rates were lower than those reported previously in national studies of medical students, IM residents, practicing physicians, IM clerkship directors, and medical school deans. Aspects of distress were more common among younger program directors, women, and those reporting greater weekly work hours. Work-home conflicts were common and associated with all domains of distress, especially if not resolved in a manner effectively balancing work and home responsibilities. Associations with program characteristics such as program size and American Board of Internal Medicine (ABIM) pass rates were not found apart from higher rates of depersonalization among directors of community-based programs (23.5 % vs. 8.6 %, p = 0.01). We did not observe any consistent associations between distress and perceptions of implementation and consequences of program regulations. CONCLUSIONS: The well-being of IM program directors across domains, including quality of life, satisfaction with work-life balance, and burnout, appears generally superior to that of medical trainees, practicing physicians, and other medical educators nationally. Additionally, it is reassuring that program directors' perceptions of their ability to respond to current regulatory requirements are not adversely associated with distress. However, the increased distress levels among younger program directors, women, and those at community-based training programs reported in this study are important concerns worthy of further study.
    Journal of General Internal Medicine 04/2013; · 3.42 Impact Factor
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    ABSTRACT: We studied whether differences exist in evaluation scores of faculty and trainees in gastroenterology (GI) based on the gender of the evaluator or evaluatee, or the evaluator-evaluatee gender pairing. We examined evaluations of faculty and trainees (GI fellows and internal medicine residents rotating on GI services), using mixed linear models to assess effects of the four possible evaluator-evaluatee gender pairings. Potential confounding variables were adjusted for, and random effects were used to account for repeated assessments. For internal medicine (IM) residents, no difference in evaluation scores based on gender was found. Resident age was negatively associated with performance rating, while percentage correct on the in-training examination (ITE) was positively associated. For GI fellows, the interaction between evaluator and evaluatee gender was significant. Fellow age and international medical graduate (IMG) status were negatively associated with performance rating, while ITE percentage correct was positively associated. For faculty, no difference was found in evaluation scores by IM residents based on the gender of the evaluated faculty or the evaluating resident, although the interaction between the evaluator and the evaluatee gender was significant. Gender had a significant marginal effect on faculty scores by GI fellows, with female faculty receiving lower scores. The interaction between evaluator and evaluatee gender was also significant for evaluations by fellows. Faculty age was negatively associated with performance rating. Gender, age, and ITE performance are associated with evaluation scores of GI trainees and faculty at our institution. The interaction of evaluator and evaluatee gender appears to play a more critical role in evaluation scoring than the gender of the evaluatee or evaluator in isolation.
    The American Journal of Gastroenterology 11/2012; 107(11):1610-4. · 9.21 Impact Factor
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    Journal of graduate medical education. 06/2012; 4(2):148-53.
  • The American journal of medicine 05/2012; 125(5):517-22. · 5.30 Impact Factor
  • The American journal of medicine 04/2012; 125(4):421-5. · 5.30 Impact Factor
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    ABSTRACT: To examine the effect of census caps and unit-based admissions on resident workload, conference attendance, duty hour compliance, and patient safety. We implemented a census cap of 14 patients on 6 Mayo Clinic internal medicine resident hospital services and a unit-based admissions process in which patients and care teams were consolidated within hospital units. All 280 residents and 15,926 patient admissions to resident and nonresident services 1 year before the intervention (September 1, 2006, through August 31, 2007) and 1 year after the intervention (May 1, 2008, through April 30, 2009) were included. Residents' workload, conference attendance, and duty hours were tracked electronically. Patient safety variables including Rapid Response Team and cardiopulmonary resuscitation events, intensive care unit transfers, Patient Safety Indicators, and 30-day readmissions were compared preintervention and postintervention. After the intervention, residents' mean (SE) ratings of workload appropriateness improved (3.10 [0.08] vs 3.87 [0.08] on a 5-point scale; P<.001), as did conference attendance (1523 [56. 8%] vs 1700 [63.5%] conferences attended; P<.001). Duty hour violations for working more than 30 consecutive hours and not having 10 hours off between duty periods decreased from 77 of 9490 possible violations (0.81%) to 27 (0.28%) and from 70 (0.74%) to 14 (0.15%) violations, respectively (both, P<.001). Thirty-day readmissions to resident services decreased (1010 [18.14%] vs 682 [15. 37%]; P<.001). All other patient safety measures remained unchanged. After adjustment for illness severity, there were no significant differences in patient outcomes between resident and nonresident services. Census caps and unit-based admissions were associated with improvements in resident workload, conference attendance, duty hour compliance, and readmission rates while patient outcomes were maintained.
    Mayo Clinic Proceedings 04/2012; 87(4):320-7. · 5.79 Impact Factor