Article

What do attending physicians contribute in a house officer-based ambulatory continuity clinic?

University of Colorado, Denver, Colorado, United States
Journal of General Internal Medicine (Impact Factor: 3.42). 06/2006; 21(5):435-9. DOI: 10.1111/j.1525-1497.2006.00423.x
Source: PubMed

ABSTRACT

To study the educational contributions of attending physicians in an internal medicine house staff ambulatory clinic.
Cross-sectional, self-administered survey.
University-affiliated general internal medicine practice.
Internal medicine residents and attendings.
Attending and resident perceptions of whether attendings made contributions to teaching points, diagnosis (DX), therapy (RX), and health care maintenance (HCM) were assessed in 428 patient encounters. Resident assessments significantly exceeded attending self-assessments of contributions to teaching points (82% vs 74%, P=.001), DX (44% vs 34%, P=.001), RX (61% vs 55%, P=.02), and HCM (19% vs 15%, P=.04). Both residents and attendings perceived that contributions declined progressively with increasing resident year (P<.05). Primary care and categorical residents assessed attending contributions comparably. However, attendings perceived contributing more to RX and HCM for categorical residents than primary care (P<.05). Male and female residents assessed attending contributions comparably. However, attendings perceived contributing generally more to DX in male residents than female (P=.003). In 8% of encounters, either residents or attendings felt that patient evaluation by the attending was needed. In these encounters with personal patient evaluation by attendings, both residents and attendings felt that attendings made more contributions to DX (P=.001) and teaching points than in other encounters.
Attending physicians consistently underestimate their perceived contributions to house officer ambulatory teaching. Their personal patient evaluation increases assistance with DX and teaching points. Given perceived declining contributions by training year, attendings may need to identify other teaching strategies for interactions with senior residents.

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What do Attending Physicians Contribute in a House Officer-Based Ambulatory
Continuity Clinic?
Elizabeth M. Cyran, MD, MSPH,
1
Gail Albertson, MD,
2
Lisa M. Schilling, MD,
2
Chen-Tan Lin, MD,
2
Lindsay Ware, BA,
2
John F. Steiner, MD, MPH,
2
Robert J. Anderson, MD
2
1
Internal Medicine Residency Program, Exempla Saint Joseph Hospital, Denver, CO, USA;
2
Division of General Internal Medicine,
University of Colorado Health Sciences Center, Denver, CO, USA.
OBJECTIVE: To study the educational contributions of attending
physicians in an internal medicine house staff ambulatory clinic.
DESIGN: Cross-sectional, self-administered survey.
SETTING: University-affiliated general internal medicine practice.
PATIENTS/PARTICIPANTS: Internal medicine residents and attend-
ings.
MEASUREMENTS AND MAIN RESULTS: Attending and resident per-
ceptions of whether attendings made contributions to teaching points,
diagnosis (DX), therapy (RX), and health care maintenance (HCM) were
assessed in 428 patient encounters. Resident assessments significant-
ly exceeded attending self-assessments of contributions to teaching
points (82% vs 74%, P
=
.001), DX (44% vs 34%, P
=
.001), RX (61% vs
55%, P
=
.02), and HCM (19% vs 15%, P
=
.04). Both residents and att-
endings perceived that contributions declined progressively with in-
creasing resident year (Po.05). Primary care and categorical residents
assessed attending contributions comparably. However, attendi ngs
perceived contributing more to RX and HCM for categorical residents
than primary care (Po.05). Male and female residents assessed attend-
ing contributions comparably. However, attendings perceived contrib-
uting generally more to DX in male residents than female (P
=
.003). In
8% of encounters, either residents or attendings felt that patient eval-
uation by the attending was needed. In these encounters with personal
patient evaluation by attendings, both residents and attendings felt
that attendings made more contributions to DX (P
=
.001) and teaching
points than in other encounters.
CONCLUSIONS: Attending physicians consistently underestimate
their perceived contributions to house officer ambulatory teaching.
Their personal patient evaluation increases assistance with DX and
teaching points. Given perceived declining contributions by training
year, attendings may need to identify other teaching strategies for
interactions with senior residents.
KEY WORDS: medical education; ambulatory care; internship and
residency; bedside training.
DOI: 10.1111/j.1525-1497.2006. 00423.x
J GEN INTERN MED 2006; 21:435–439.
I
n recent years, medical education has increasingly empha-
sized training in ambulatory medical practice sites.
1
The
Accreditation Council for Graduate Medical Education now
specifies that 25% of all training be in ambulatory sites.
2
Pro-
gram objectives and formats for ambulatory care training have
been described.
2–5
However, there is little information about
the effectiveness of attending teaching contributions in ambu-
latory medical education. Nor is there substantial information
regarding the educational experience and learning outcomes of
medical residents in these settings.
6,7
In contrast to hospital
inpatient settings where faculty members, subspecialty
fellows, students, and senior residents all contribute to teach-
ing, the ambulatory setting generally consists of brief, 1-on-1
interactions between attending and trainee while patients are
waiting. Furthermore, discussion time may be devoted to only
the most acute medical problems, and neither the attending
nor the resident can prepare ahead of time for the clinical dis-
cussion, as patient problems may be unpredictable and
data may be incomplete.
8
These differences may impact the
effectiveness of attending teaching contributions.
Understanding the resident education process in ambu-
latory settings is useful to develop ways in which attendings
can teach more effectively. The purpose of this study was to
assess the frequency with which residents and attending pre-
ceptors perceived that contributions were made to diagnosis,
therapy, health care maintenance (HCM), and general teaching
issues in an internal medicine house staff ambulatory clinic.
Additionally, resident characteristics that might alter percep-
tions of attending contributions were evaluated. Finally,
the effect of personal patient evaluations by attendings was
assessed.
METHODS
Setting, Patients, and Physicians
This cross-sectional study took place in a resident ambulatory
internal medicine continuity group practice associated with
the University of Colorado Health Sciences Center. Approxi-
mately 30% to 40% of patients were insured by a Medicaid
health maintenance organization, 30% to 40% by Medicare,
and 30% to 40% by other sources (self-pay, commercial insur-
ance, or other HMOs). All patient encounters were eligible for
study. Two to 4 scheduled house officer-patient encounters
were selected randomly at the beginning of each clinic session
for invitation for study participation. Forty-two categorical in-
ternal medicine, primary care track internal medicine, and
preliminary track residents participated. Attending physicians
consisted of 14 board-certified, primary care internists affili-
ated with the University of Colorado Health Sciences Center
who precepted in resident clinic one half-day session per week
and had no other patient care responsibilities during clinic.
Two to 8 residents were scheduled in a typical clinic session,
with 1 to 3 attendings present. The resident-attending ratio
was less than 4:1. Residents were not assigned to work with a
specific attending. Residents and attendings had worked with
each other for at least 6 months prior to the study, but the
number of sessions together was highly variable and influ-
enced by inpatient-service-related clinic rescheduling, and
vacations. The study was conducted between January and
June 1999.
Address correspondence and requests for reprints to Dr. Cyran:
Exempla Saint Joseph Hospital, 1835 Franklin Street, Denver, CO
80218 (e-mail: cyrane@exempla.org).
435
Page 1
Study Design
During regular clinic time and immediately after the randomly
selected house officer-patient visit, the resident and the at-
tending with which they had staffed the patient were invited to
independently and anonymously complete questionnaires re-
garding the teaching encounter. A teaching encounter was
defined as a 1-on-1 discussion between the resident and at-
tending physician regarding the patient visit. The patient was
asked to complete a questionnaire regarding their overall
health, visit satisfaction, and demographic information. Writ-
ten informed consent was obtained from all study participants.
No patient or physician refused to participate. All encounters
took place in the second 6 months of the academic year, when
an attending-patient interaction was not mandatory under
physical presence exception rules, but occurred if the attend-
ing or house officer felt that attending patient evaluation was
necessary.
Survey Instrument and Outcome Measures
A questionnaire to measure attending teaching contributions
was designed, using input from clinician educators and med-
ical education investigators during small group discussions.
The questionnaire was revised for clarity and completeness of
content based on results of pilot surveys. For each patient en-
counter, the attending and the house officer were asked to
provide ‘‘yes’’ or ‘‘no’’ responses to 3 questions: ‘‘Did the at-
tending physician make contributions with regard to diagno-
sis?’’ ‘‘Did the attending physician make contributions with
regard to therapy/management?’’ ‘‘Did the attending physi-
cian make contributions with regard to health care mainte-
nance?’’ The respondents were asked to further subcategorize
attending contributions. Subcategories for attending contri-
butions regarding diagnosis included recommendations for
additional history or records, examinations, tests or proce-
dures, referrals, and suggestions of additional diagnoses. Sub-
categories for attending contributions regarding therapy
included recommendations regarding stopping, starting,
changing, or continuing medications, recommendations for
procedures, referrals, patient education materials, or for
change in monitoring/follow-up. An additional fourth ques-
tion asked the respondent to indicate whether any teaching
points were made regarding diagnoses, therapy, health main-
tenance, communication, documentation, medical-legal is-
sues, insurance-referral-billing issues, or other issues. The
terms ‘‘contributions’’ and ‘‘teaching points’’ were left to the
interpretation of the participant completing the questionnaire
and were not further defined. Both residents and attendings
were also asked ‘‘Did you and the attending initially differ
over diagnostic and/or therapeutic assessment in this case?’’
Finally, the residents were asked to provide information on
their gender, year of training (first, second, or third), and train-
ing track (categorical or primary care). A single professional
research assistant obtained informed consent and collected all
study questionnaires from house officers, attending physi-
cians, and patients.
The study was approved by the University of Colorado
Multiple Institution Review Board (COMIRB).
Data Analysis
Teaching contributions were categorized into the following do-
mains: diagnosis (DX), therapy (RX), HCM, and general teach-
ing points. The frequency of ‘‘yes’’ responses (indicating a
positive teaching contribution) to each of the 3 ‘‘yes/no’’ ques-
tions was determined. For the fourth question on teaching
points, any checked category indicated that a teaching contri-
bution was made. The individual house officer-attending in-
teraction was the unit of analysis. McNemar’s test for paired
data was used to evaluate the statistical significance of differ-
ences between resident and attending perceptions of teaching
contributions. Within the separate strata of resident responses
and faculty responses, the effect of residency track and gender
were evaluated using standard w
2
tests for bivariate compar-
isons. The effect of year of training was evaluated using the w
2
test for trend. All statistical analyses were conducted with SAS
statistical software (SAS Institute, Inc., Cary, NC).
RESULTS
Fourteen attending physicians (9 male and 5 female), and 42
residents participated in the survey. Twelve residents (29%)
were in the primary care track, 28 (67%) were in the categorical
track, and 2 (4%) were preliminary 1-year residents. Sixty per-
cent were male and 40% were female. They were nearly evenly
divided between the first through third years of training (31%
first year, 29% second year and 40% third year). Overall, 428
patient encounters were assessed. The patient characteristics
were as follows: 68% were female, 52% were ages 45 to 64, 25%
were over age 65, 67% had a high school education or less,
87% had an annual income of $15,000 or less, 43% were of a
minority race/ethnicity, and 50% self-rated their health as
‘‘poor or fair.’’
Residents assessed that attendings made teaching con-
tributions to most cases. This significantly exceeded attending
self-assessment of their teaching contributions, as shown in
Figure 1. Teaching point contributions were present in 82% of
cases as assessed by residents versus 74% of cases as as-
sessed by attendings (P
=
.001), diagnosis contributions were
present in 44% of cases as assessed by residents versus 34%
as assessed by attendings (P
=
.001), therapy contributions in
61% of cases as assessed by residents versus 55% as assessed
by attendings (P
=
.02), and HCM in 19% of cases as assessed
by residents versus 15% as assessed by attendings (P
=
.04).
Figures 2 and 3 demonstrate that both resident and at-
tending assessments of attending contributions to teaching
100
90
80
70
60
50
40
30
20
10
0
Teachin
g
p = 0.001
p = 0.001
p = 0.02
p = 0.04
Percent of Encounters with
Attending Contributions
DX RX HCM
FIGURE 1. Attending and resident assessment of contributions. The
attending response frequency is shown as the black bar and the
resident response frequency is shown by the white bar.
436 JGIMCyran et al., Educational Contributions of Attending Physicians
Page 2
points, diagnosis, therapy, and HCM progressively decreased
with each increasing year of resident experience. For example,
teaching point contributions were reported by first-year post-
graduate residents (PGY1) to be present in 91% of cases, by
second-year postgraduate residents (PGY2) in 91% of cases,
and by third-year postgraduate residents (PGY3) in 74% of
cases (P
=
.001), and therapy contributions were reported to be
present in 80% of cases (PGY1), 70% of cases (PGY2), versus
48% of cases (PGY3) (P
=
.001). Attending perceptions were
similar with teaching points reported present in 85% of
PGY1, 78% of PGY2, versus 66% of PGY3 (P
=
.001), and ther-
apy contributions present in 70% PGY1, 53% PGY2, versus
49% of PGY3 (P
=
.001).
Primary care and categorical residents assessed attending
teaching contributions comparably for all categories. However,
attendings felt they made more contributions to therapy and
HCM in categorical than primary care house officers (RX 58%
vs 47%, P
=
.03 and HCM 18% vs 8%, P
=
.004). Male and fe-
male residents assessed attending contributions to diagnosis,
therapy and HCM comparably, however, female residents more
frequently than male residents perceived that attendings made
teaching points (88% vs 78%, P
=
.02). In contrast, attending
perceptions of contributions were generally greater for male
than female residents. Attendings perceived teaching contri-
butions were made during 77% of male versus 69% of female
resident teaching encounters, P
=
.07, and that diagnosis con-
tributions were made during 40% of male versus 25% of female
resident teaching encounters, P
=
.003. Both residents and att-
endings felt that there were rarely differences between each
other with regard to the overall diagnosis or therapy plan for
patients (data not shown).
In 8% of encounters, either residents or attendings felt
that personal evaluation of the patient by the attending was
needed. Figure 4 shows the results of the questions in this
circumstance. When attending evaluation was deemed neces-
sary, both residents and attendings felt that attendings made
more contributions to teaching points (97% vs 82%, P
=
.02)
and diagnosis (74% vs 44%, P
=
.001) than in encounters when
attendings did not see the patient.
The results of the subcategories for each of the 3 ‘‘yes/no’’
questions were reviewed to assess attending contributions
more specifically. The most frequent subcategories of attend-
ing contributions as rated by residents were suggestions
regarding stopping, starting, or changing medications, sug-
gestions regarding additional tests or diagnostic procedures,
and suggestions regarding additional history, diagnoses, or
changes in monitoring/follow-up. In several of these subcate-
gories, residents perceived that attendings made teaching con-
tributions significantly more frequently than attendings self-
assessed their contributions. Residents perceived that recom-
mendations for additional history and referral suggestions
were significant attending teaching contributions (P
=
.005).
Additionally, recommendations for changes in monitoring/fol-
low-up were rated as significant attending teaching contribu-
tions (P
=
o.01).
DISCUSSION
Attending physicians are perceived to make frequent contri-
butions to house officer ambulatory education, but generally
underestimate themselves. This underestimation is similar to
a study by O’Malley, which found that learners (interns and
third-year medical students) were significantly more likely
than their teachers to rate the overall educational value of an
encounter as ‘‘excellent’’ or ‘‘very good.’’
9
The reason for this
underestimation is unclear, but there are several possible ex-
100
90
80
70
60
50
40
30
20
10
0
Teachin
g
Percent of Encounters with
Attending Contributions
DX RX HCM
p = 0.001
p = 0.001
p = 0.003
NS
FIGURE 2. Resident assessment of attending contributions by year
of training. Resident postgraduate year 1 (PGY1) response fre-
quency is shown by the black bar, PGY2 response frequency is
shown by the grey bar, and PGY3 response frequency is show by
the white bar.
100
p = 0.001
p = 0.001
NS
p = 0.05
90
80
70
60
50
40
30
20
10
0
Teachin
g
Percent of Encounters with
Attending Contributions
DX RX HCM
FIGURE 3. Attending assessment of contributions by resident train-
ing year. Attending assessment of frequency of teaching contri-
butions to resident postgraduate year 1 (PGY1) is shown by the
black bar, to PGY2 by the grey bar, and to PGY3 by the white bar.
100
p = 0.02
p = 0.001
NS
NS
90
80
70
60
50
40
30
20
10
0
Teachin
g
Percent of Encounters with
Attending Contributions
DX RX HCM
FIGURE 4. Residents felt attendings contributed more to teaching
and diagnosis when attendings evaluated patients. The frequency
of teaching contributions when attendings personally evaluated
patients is shown by the black bar, and the white bar indicates
frequency of teaching contributions when the attending did not
see the patient.
JGIM 437Cyran et al., Educational Contributions of Attending Physicians
Page 3
planations. First, in our study, residents perceived more com-
monly than attendings that attendings provided teaching con-
tributions by suggesting additional history, referrals, and
changes in patient monitoring/follow-up. Perhaps attendings
think these activities are part of routine patient care manage-
ment, rather than teaching contributions. Additionally, att-
endings may underestimate the effects of role modeling
professional behavior (although residents were not specifical-
ly questioned on this issue).
10
Finally, attendings may not
recognize that confirmation of a resident’s management plan
is a teaching contribution. This possibility is supported by
findings in a study by Laidley evaluating whether attendings
recognized residents’ learning need.
11
The learning need most
commonly identified by residents in the study by Laidley
was ‘‘validation of impression and plan,’’ which they chose
more often than ‘‘differential diagnosis’’ or ‘‘verifying a physical
finding.’’
11
This suggests that an attending confirmation of
patient management could be considered a teaching contri-
bution by residents. Future studies could specifically query
residents and attendings on these issues to explore whether
they are significant teaching contributions, which in turn
would help facilitate understanding resident ambulatory
education.
Both residents and attendings perceived that attendings
contributed less as residents advanced in their training. Intu-
itively, this is not surprising. Both attendings and residents
reported that teaching contributions were most frequently to
therapy followed by diagnoses, and as residents expand their
knowledge base with training, they would need less attending
input into these patient management issues. However, it may
also mean that attendings expect that senior residents need
less teaching, and thus they provide less teaching than nec-
essary. Xakellis
12
found that mean faculty teaching time in an
ambulatory clinic was greater for first-year residents than
third-year residents. Attendings may need to develop teaching
strategies for additional educational areas of emphasis that
could be directed to senior residents (e.g., evidence-based
medicine, prevention, time management, cost-containment,
and managed care practices). Additionally, senior residents
could be provided opportunities to teach and supervise others
in ambulatory medicine settings (much as they teach in the
inpatient setting), as it is a widely recognized belief that teach-
ing others improves self-learning.
It is possible that resident-attending continuity with each
other affected perceptions of teaching by year, in that the long-
er that residents and attendings worked with each other, the
more likely they both assumed that the resident knew all they
needed to know about their patient. Unfortunately, we were
unable to retrospectively track the amount of continuity resi-
dents had with specific attendings over their training. Howev-
er, residents did not present to the same attending every
encounter, and may not have worked with the same faculty
their entire 3 years because of changes in clinic days and
attending composition.
Resident training track and gender had some affect on
attending self-perceptions of their teaching contributions. Per-
haps attendings assumed that primary care residents have
more experience with HCM and therapy of outpatient prob-
lems, and felt they needed to contribute less. The differences in
teaching perceptions related to resident gender are more diffi-
cult to explain. Gender differences have been found in medical
school grading and in numerical scores from the American
Board of Internal Medicine evaluation forms.
13–15
Additionally,
differences in teaching related to the gender composition of the
teacher-student pair have been found during ambulatory pa-
tient encounters.
16
However, we did not collect gender data on
the attending-resident dyad for each of the encounters we
studied. This would be another interesting area of study.
Bedside evaluation of the patient by the attending signif-
icantly increased the frequency of teaching contributions, al-
though it is interesting to note that only a small number of
cases (8%) were deemed necessary for the attending to see.
While bedside teaching is proposed to have many benefits in-
cluding the teaching of history and exam skills, humanism,
professionalism, communication, and role-modeling, esti-
mates are that it occurs only 15% to 25% of the time, and that
direct observation of learners occurs less than 5% of the
time.
17
The reasons for bedside teaching decline is not clear,
although previous articles suggest that while patients value
bedside teaching, residents are more uncomfortable with bed-
side presentations, and there are many attending barriers in-
cluding concerns over lack of experience, time, and skills.
17,18
We do not have data on the types of patient encounters that
necessitated personal attending-patient interaction, whether
the teaching contributions of attending patient evaluations
were confined to certain types of patient problems, or wheth-
er the desire for bedside evaluation was driven by the resident
or attending. We also do not have data on whether the in-
creased perception of teaching was due to greater time spent
by the attending with the house officer, or whether a focus on
history, exam, or something else contributed to their teaching
benefit. These would all be useful areas to explore. However,
our overall results are consistent with those of Gennis, who
found that outpatient teaching was influenced by whether the
attending saw the patient or not.
19
Whether an attendings un-
derestimation of their teaching contributions has any impact
on their frequency of bedside teaching also cannot be deter-
mined from our study. However, perhaps attendings would
teach from the bedside more enthusiastically and frequently if
they realize how valuable their contributions are. Useful tech-
niques to help facilitate attendings confidence in bedside
teaching have been published.
20,21
Our data underscore the
educational importance of attending bedside sessions.
A number of limitations of our study should be men-
tioned. The study took place at a single institution and ambu-
latory clinic site, with a relatively modest number of house
officers and attendings. However, encounters were spread out
among the 14 attendings, rather than a few attendings pre-
cepting the majority of cases. Patients were of lower income
and education, and there were more minority patients than in
the general population. Therefore, our results may not be gen-
eralizeable. Additionally, we developed our own questionnaire,
which relied on self-reported perceptions of teaching contri-
butions during unique, nonreproducible encounters. Without
doing independent observations of teaching contributions, the
instrument could not be formally evaluated for validity or re-
liability. While the domains of teaching contributions (diagno-
sis, therapy, HCM) were reasonable, there may have been
overlap across domains in some instances and misclassifica-
tion of some teaching points. House officers and attending
physicians were aware that research studies were ongoing and
that their clinical behavior was under scrutiny. This may have
influenced the frequency of reported teaching contributions.
Our study was not designed to assess the educational impact
438 JGIMCyran et al., Educational Contributions of Attending Physicians
Page 4
of attending teaching on residents’ skills or patient outcomes.
Finally, visit duration, time pressure, number of interruptions,
continuity of resident with attending (number of clinic ses-
sions worked together), and the ratio of residents to attending
all may have affected our results. We did not gather informa-
tion on these factors.
CONCLUSIONS
Attending physicians are perceived to make significant contri-
butions to house officer ambulatory education and patient
care, which they generally underestimate. Their bedside eval-
uation of patients aids in diagnosis and teaching. Resident
variables affect perceptions of attending contributions. Fur-
ther studies are necessary to measure more precisely aspects
of ambulatory teaching effectiveness, such as: assessing at-
tending educational impact on resident learning outcomes and
skills; why certain encounters or teaching situations are ef fec-
tive for both attending and resident; and what are common
situations in which the attending should see the patient to aid
in diagnosis. Finally, to maintain teaching contributions, att-
endings could consider emphasizing other areas of ambulatory
practice to residents as they mature in their training.
REFERENCES
1. Perkoff GT. Teaching clinical medicine in the ambulatory setting. N Engl
J Med. 1986;314:27–31.
2. Halperin AK, Kaufman A. Ambulatory medical education: a reconsid-
eration of sites and teachers. J Gen Intern Med. 1990;5(suppl):
S35–44.
3. Hewson MG. Clinical teaching in the ambulatory setting. J Gen Intern
Med. 1992;7:76–82.
4. Branch WT. Teaching models in an ambulatory training program. J Gen
Intern Med. 1990;5:S15–26.
5. Lesky LG, Borkan SC. Strategies to improve teaching in the ambulatory
medicine setting. Arch Intern Med. 1990;150:2133–7.
6. McGlynn TJ, Wynn JB, Munzenrider RF. Resident education in prima-
ry care: how residents learn. J Med Educ. 1978;53:973–81.
7. Bordage G, Burack JH, Irby DM, Stritter FT. Education in ambulatory
settings: developing valid measures of educational outcomes, and other
research priorities. Acad Med. 1998;73:743–50.
8. Wones RG, Rouan GW, Brody TL, Bode RB, Radack KL. An ambulatory
medical education program for internal medicine residents. J Med Educ.
1987;62:470–6.
9. O’Malley PG, Kroenke K, Ritter J, Dy N, Pangaro L. What learners and
teachers value most in ambulatory educational encounters: a prospec-
tive, qualitative study. Acad Med. 1999;74:186–91.
10. Quill TE. Medical resident education: a cross-sectional study of the in-
fluence of the ambulatory preceptor as a role model. Arch Intern Med.
1987;147:971–3.
11. Laidley TL, Braddock CH, Fihn SD. Did I answer your question? At-
tending physicians’ recognition of residents perceived learning needs in
ambulatory settings. J Gen Intern Med. 2000;15:46–50.
12. Xakellis GC, Gjerde CL. Ambulatory medical education: teachers’ ac-
tivities, teaching cost, and residents’ satisfaction. Acad Med. 1995;70:
702–7.
13. Wang-Chen RM, Fulkerson PK, Barnas GP, Lawrence SL. Effect of stu-
dent and preceptor gender on clinical grades in an ambulatory care
clerkship. Acad Med. 1995;70:324–6.
14. Day SC, Norcini JJ, Shea JA, Benson JA Jr. Gender differences in the
clinical competence of residents in internal medicine. J Gen Intern Med.
1989;4:309–12.
15. Rand VE, Hudes ES, Browner WS, Wachter RM, Avins AL. Effect of
evaluator and resident gender on the American Board of Internal Med-
icine evaluation scores. J Gen Intern Med. 1998;13:670–4.
16. Carney PA, Dietrich AJ, Eliassen S, Pipas C, Donahue D. Differences
in ambulatory teaching and learning by gender match of preceptors and
students. Fam Med. 2000;32:618–23.
17. Ramani S, Orlander JD, Strunin L, Barber W. Whither bedside teaching
a focus-group study of clinical teachers. Acad Med. 2003;78:384–90.
18. Anderson RJ, Cyran E, Schilling L, et al. Outpatient case presenta-
tions in the conference room versus examination room: results from two
randomized controlled trials. Am J Med. 2002;113:657–62.
19. Gennis VM, Gennis MA. Supervision in the outpatient clinic: effects on
teaching and patient care. J Gen Intern Med. 1993;8:378–80.
20. Ramani S. Twelve tips to improve bedside teaching. Med Teacher.
2003;25:112–5.
21. Kroenke K, Omori D, Landry FJ, Lucey CR. Bedside teaching. South-
ern Med J. 1997;90:1069–74.
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    [Show abstract] [Hide abstract] ABSTRACT: Parsimony, and not industry, is the immediate cause of the increase of capital. Industry, indeed, provides the subject which parsimony accumulates. But whatever industry might acquire, if parsimony did not save and store up, the capital would never be the greater.Adam Smith, The Wealth of Nations, book 2, chapter 31In 2003, the Accreditation Council for Graduate Medical Education implemented resident duty hour limits that included a weekly limit and limits on continuous hours. Recent recommendations for added reductions in resident duty hours have produced concern about concomitant reductions in future graduates' preparedness for independent practice. The current debate about resident hours largely does not consider whether all hours residents spend in the educational and clinical-care environment contribute meaningfully either to residents' learning or to effective patient care. This may distract the community from waste in the current clinical-education model. We propose that use of "lean production" and quality improvement methods may assist teaching institutions in attaining a deeper understanding of work flow and waste. These methods can be used to assign value to patient- and learner-centered activities and outputs and to optimize the competing and synergistic aspects of all desired outcomes to produce the care the Institute of Medicine recommends: safe, effective, efficient, patient-centered, timely, and equitable. Finally, engagement of senior clinical faculty in determining the culture of the care and education system will contribute to an advanced social-learning and care network.
    Full-text · Article · Dec 2009
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    [Show abstract] [Hide abstract] ABSTRACT: Graduate medical education is based on an on-the-job training model in which residents provide clinical care under supervision. The traditional method is to offer residents graduated levels of responsibility that will prepare them for independent practice. However, if progressive independence from supervision exceeds residents' progressive professional development, patient outcomes may be at risk. Leaders in graduate medical education have called for "optimal" supervision, yet few studies have conceptually defined what optimal supervision means and whether optimal care is theoretically compatible with progressive independence, nor have they developed a test for progressive independence. This research develops theory and analytic models as part of the Resident Supervision Index to quantify the intensity of supervision. We introduce an explicit set of assumptions for an ideal patient-centered theory of optimal supervision of resident-provided care. A critical assumption is that informed attending staff will use available resources to optimize patient outcomes first and foremost, with residents gaining clinical competencies by contributing to optimal care. Next, we derive mathematically the consequences of these assumptions as theoretical results. Under optimal supervision, (1) patient outcome is expected to be no worse than if residents were not involved, (2) supervisors will avoid undersupervising residents (when patients are at increased risk for poor outcomes) or oversupervising residents (when residents miss clinical opportunities to practice care), (3) optimal patient outcomes will be compatible with progressive independence, (4) progressive development can be inferred from progressive independence whenever residents contribute to patient care, and (5) analytic models that test for progressive independence will emphasize adjusting the association between length of graduate medical education training and supervision for case complexity and clinic workload, but not patient health outcomes. An explicit theoretical framework is critical to measure scientifically progressive independence from supervision using graduate medical education data.
    Full-text · Article · Mar 2010
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    [Show abstract] [Hide abstract] ABSTRACT: To develop a survey instrument designed to quantify supervision by attending physicians in nonprocedural care and to assess the instrument's feasibility and reliability. In 2008, the Department of Veterans Affairs (VA) Office of Academic Affiliations convened an expert panel to adopt a working definition of attending supervision in nonprocedural patient care and to construct a survey to quantify it. Feasibility was field-tested on residents and their supervising attending physicians at primary care internal medicine clinics at the VA Loma Linda Healthcare System in their encounters with randomly selected outpatients diagnosed with either major depressive disorder or diabetes. The authors assessed both interrater concurrent reliability and test-retest reliability. The expert panel adopted the VA's definition of resident supervision and developed the Resident Supervision Index (RSI) to measure supervision in terms of residents' case understanding, attending physicians' contributions to patient care through feedback to the resident, and attending physicians' time (minutes). The RSI was field-tested on 60 residents and 37 attending physicians for 148 supervision episodes from 143 patient encounters. Consent rates were 94% for residents and 97% for attending physicians; test-retest reliability intraclass correlations (ICCs) were 0.93 and 0.88, respectively. Concurrent reliability between residents' and attending physicians' reported time was an ICC of 0.69. The RSI is a feasible and reliable measure of resident supervision that is intended for research studies in graduate medical education focusing on education outcomes, as well as studies assessing quality of care, patient health outcomes, care costs, and clinical workload.
    Full-text · Article · Mar 2010 · Academic medicine: journal of the Association of American Medical Colleges
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