Supervision in the outpatient clinic

Gennis, Virginia M.; Gennis, Mark A.

doi:10.1007/bf02600077

Cited by 36 publications

(4 citation statements)

References 2 publications

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“…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 underestimation of their teaching contributions has any impact on their frequency of bedside teaching also cannot be determined from our study.…”

Section: Discussionsupporting

confidence: 90%

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

et al. 2006

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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 attendings. MEASUREMENTS AND MAIN RESULTS: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 (Po.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 (Po.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. 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. I n recent years, medical education has increasingly emphasized 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 Program 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 ambulatory 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 teaching, 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 discussion, as patient problems may be unpredictable and data may be incomplete. 8 These differenc...

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Section: Discussionsupporting

confidence: 90%

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

et al. 2006

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“…It is not clear whether a similar level of supervision is required for procedural skills vs cognitive decision making. In the outpatient setting, Gennis and Gennis found that preceptors who directly saw patients judged them to be more severely ill than residents did and made major diagnostic changes in 5.5% of the patients, but there were no patient safety outcomes studied. Patient safety outcomes were evaluated in ICU studies after calls for 24 hours a day, 7 days a week intensivist coverage in ICUs due to higher death rates on weekends and at night .…”

Section: Discussionmentioning

confidence: 99%

Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education

et al. 2018

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IMPORTANCE While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety. OBJECTIVE To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes. DESIGN, SETTING, AND PARTICIPANTS This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program. INTERVENTIONS Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order. MAIN OUTCOMES AND MEASURES The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. RESULTS Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04). CONCLUSIONS AND RELEVANCE Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy.

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“…Unfortunately, case presentations may not accurately represent what transpired in the resident-patient encounter. 51,52 In our faculty development work, we have heard countless stories of faculty experiencing profound discordance between what they heard from a case presentation and what they discovered when they saw the patient directly. 53 Singh and colleagues also found that diagnostic error in an ambulatory visit was a common reason for unexpected patient return visits within 14 days, highlighting the importance of appropriate supervision of accurate medical interview and physical examination skills for patients presenting with new signs and symptoms.…”

Section: The Variation Cascadementioning

confidence: 99%

Will Any Road Get You There? Examining Warranted and Unwarranted Variation in Medical Education

Holmboe¹,

Kogan²

2022

Academic Medicine

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Undergraduate and graduate medical education have long embraced uniqueness and variability in curricular and assessment approaches. Some of this variability is justified (warranted or necessary variation), but a substantial portion represents unwarranted variation. A primary tenet of outcomesbased medical education is ensuring that all learners acquire essential competencies to be publicly accountable to meet societal needs. Unwarranted variation in curricular and assessment practices contributes to suboptimal and variable educational outcomes and, by extension, risks graduates delivering suboptimal health care quality. Medical

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Supervision in the outpatient clinic

Cited by 36 publications

References 2 publications

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

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

Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education

Will Any Road Get You There? Examining Warranted and Unwarranted Variation in Medical Education

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