Internal Medicine Residents’ Perceptions of Team-Based Care and its Educational Value in the Continuity Clinic: A Qualitative Study

Abstract

BACKGROUND :In order to teach residents how to work in interprofessional teams, educators in graduate medical education are implementing team-based care models in resident continuity clinics. However, little is known about the impact of interprofessional teams on residents' education in the ambulatory setting. OBJECTIVE: To identify factors affecting residents' experience of team-based care within continuity clinics and the impact of these teams on residents' education. DESIGN: This was a qualitative study of focus groups with internal medicine residents. PARTICIPANTS: Seventy-seven internal medicine residents at the University of California San Francisco at three continuity clinic sites participated in the study. APPROACH: Qualitative interviews were audiotaped and transcribed. The authors used a general inductive approach with sensitizing concepts in four frames (structural, human resources, political and symbolic) to develop codes and identify themes. KEY RESULTS: Residents believed that team-based care improves continuity and quality of care. Factors in four frames affected their ability to achieve these goals. Structural factors included communication through the electronic medical record, consistent schedules and regular team meetings. Human resources factors included the presence of stable teams and clear roles. Political and symbolic factors negatively impacted team-based care, and included low staffing ratios and a culture of ultimate resident responsibility, respectively. Regardless of the presence of these factors or resident perceptions of their teams, residents did not see the practice of interprofessional team-based care as intrinsically educational. CONCLUSIONS: Residents' experiences practicing teambased care are influenced by many principles described in the interprofessional teamwork literature, including understanding team members' roles, good communication and sufficient staffing. However, these attributes are not correlated with residents' perceptions of the educational value of team-based care. Including residents in interprofessional teams in their clinic may not be sufficient to teach residents how team-based care can enhance their overall learning and future practice.

Charting a Key Competency Domain: Understanding Resident Physician Interprofessional Collaboration (IPC) Skills

“…Direct workplace observation of a resident giving feedback to an interprofessional colleague may not be feasible and simply placing learners in team-based care may be insufficient to teach these skills. 23,24 Performance-based assessment such as OSCEs may be an ideal, efficient strategy for providing program needs assessments and educational opportunities in these critical but difficult to directly observe milestones.…”

Are role perceptions of residents and nurses translated into action?

“…Given the importance of role clarity with regard to IPC [ 3 , 4 ], we sought to delve deeper into this issue by analyzing whether or not various components of residents’ and nurses’ roles were translated into action. Role components for which participants’ actions matched their perceptions may be understood as favoring collaborative practice.…”

“…Analyzing how healthcare teams work together, Grumbach and Bodenheimer [ 3 ] observed that having common and well-defined goals, institutional stability, being trained to perform one’s role, communication, and role clarity were essential elements of IPC. Professional role therefore represents an important aspect of IPC [ 4 ].…”

“…Further work on role clarity in healthcare has stressed the limited knowledge that professionals have of groups other than their own, and the negative impact this could have on interprofessional collaboration [ 4 , 17 , 18 ]. Van Schaik and colleagues [ 19 ] identified knowledge of one’s own role, as well as of others’ roles, as critical to IPC in lower-acuity settings.…”

Time for System Redesign

“…Soones et al provide some insight into interprofessional collaborative care through a qualitative study that explores the factors internal medicine residents identified as affecting their ability to provide and learn about interprofessional team-based care, with a focus on residents' continuity clinics. 8 Although residents believed teams could improve patient care and healthcare provider job satisfaction, the opportunities to experience this and learn from these experiences were hindered by the system within which they worked. Specific challenges included absences created by residents' schedules, frequent team member turnover, low staffing ratios, and a negative cultural perception that residents will do all of the work when teams break down.…”