IMPORTANCE COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models. OBJECTIVE To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients. DESIGN, SETTING, AND PARTICIPANTS The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15,

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Background Clinical continuity is recognized as a driver of satisfaction for patients and physicians. Greater continuity may positively affect trainee decisions to enter primary care. Maintaining clinical continuity remains a challenge in residency clinics. Objective We determined whether enhanced scheduling support was associated with improvement in internal medicine resident continuity with patients. Methods This study was conducted from June 2017 to December 2018. In the intervention clinic, a single scheduling staff member (ratio of 10 residents to 1 scheduler) was colocated within the clinical space, allowing the scheduler to participate in clinical discussions and direct communication with physicians regarding future appointments. In the comparison clinic, scheduling staff (19:1 ratio) were located at a remote front desk area and relied on patient reports or electronic health record orders to identify appointment needs and arrange follow-up appointments. The main outcome of the intervention was resident continuity, calculated using the continuity for physician formula. Results During the study period, mean resident continuity was 23% (range 13%–37%) in the comparison clinic (57 residents) and 54% (range 38%–66%) in the intervention clinic (10 residents). Resident continuity was significantly higher in the intervention clinic compared with the traditional control clinic for every quarter measured ( P < .001 for all comparisons). Conclusions Enhancing scheduling support through colocation and a lower resident to scheduler ratios was associated with significantly higher rates of resident continuity compared with a traditional front desk model, with results sustained over 18 months.

Introduction: Contract negotiation is a high-stakes interaction, yet most physicians are never taught negotiation skills. Studies suggest that women, as compared with men, display a lower propensity to initiate negotiations and negotiate less competitively, highlighting a need for training to help level the playing field for female physicians. Methods: We devised a learner-centered workshop for female physicians that included a mini-didactic on negotiation principles, a question-and-answer time with a lawyer, an interactive role-play on contract negotiation style, and guided reflection. The workshop was intended for women in medicine from the level of medical student to full professor. The workshop was evaluated by pre-and postworkshop surveys with quantitative questions assessing perceived comfort with and knowledge of negotiation skills and strategies, as well as qualitative questions assessing lessons learned and areas for improvement. Results: After the workshop, participants (n = 34) reported significantly improved comfort with contract negotiation (p < .01) and with negotiation skills and strategies (p < .01). Through qualitative evaluation, we discovered that participants gained an appreciation for the self-advocacy in negotiation, as well as a better understanding of negotiation logistics. We also received positive feedback from participant comments, with most learners reporting that the topic was useful and worthwhile. Discussion: We believe that this workshop fills a gap in the literature regarding contract negotiation training for physicians while also helping to level the playing field with regard to female physicians and the gender pay gap.

Background: Increasingly, residents are being trained in Patient-centered Medical Home (PCMH) settings. A set of PCMH entrustable professional activities (EPAs) for residents has been defined but not evaluated in practice. Objective: To understand whether residents trained at PCMH sites reported higher likelihood of engaging in PCMH tasks than those training in non-PCMH sites. Design: Survey and nominal group data from post-graduate trainees at three residency programs. Results: A total of 179 residents responded (80% response). Over half (52%) cared for patients at PCMH sites. Residents at PCMH sites were more likely to report engaging in tasks in the NCQA domains of enhancing access and continuity (p < 0.01 for 4/11 tasks), planning and managing care (p < 0.01 for 3/4 tasks), providing self-care and community support (p < 0.01 for 3/5 tasks), and identifying and managing patient populations (p < 0.01 for 1/6 tasks), but were not more likely to report tracking and coordinating care or measuring and improving performance. Residents at PCMH sites were more likely to report working with medical assistants (p < 0.01), but not other healthcare professionals. Qualitative data showed staff teamwork and continuity of care as facilitators of patient-centered care, and technological problems and office inefficiencies as barriers to care. Conclusions: Residents trained at PCMH sites were more likely to engage in tasks in several NCQA domains, but not care coordination and quality assessment. Similar facilitators and barriers to trainee provision of patient-centered care were cited regardless of PCMH status. Curricula on PCMH principles and workflows that foster continuity and communication may help to inform residents on PCMH tenets and incorporate residents into team-based care. Abbreviations: EPA: Entrustable professional activity; GIM: General Internal Medicine; NCQA: National Center for Quality Assurance; PCMH: Patient-centered medical home

Background Team-based care is recommended as a building block of high-performing primary care but has not been widely adapted in training sites. Cost may be one barrier to a team-based approach. Objective We quantified incremental annual faculty and staff costs as well as potential cost savings associated with an interprofessional (IP) ambulatory training program compared to a traditional residency clinic at the same site. Methods Cost calculations for the 2017–2018 academic year were made using US Department of Labor median salaries by profession and divided by the number of residents trained per year. Cost implications of lower no-show rates were calculated by multiplying the difference in no-show rate by the number of scheduled appointments, and then by the weighted average of the reimbursement rate. Results A total of 1572 arrived appointments were seen by the 10 residents in the IP program compared with 8689 arrived appointments seen by 57 residents in the traditional clinic. The no-show rate was 11.5% (265 of 2311) in the IP program and 19.2% (2532 of 13 154) in the traditional clinic (P &lt; .001). Total cost to the health system through higher staffing needs was $113,897, or $11,390 per trained resident. Conclusions Total costs of the IP model due to higher faculty and staff to resident ratios totaled $11,390 per resident per year. Understanding the faculty and staff costs and potential cost-saving opportunities associated with transformation to an IP model may assist in sustainability.

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