What Makes the “Perfect” Inpatient Consultation? A Qualitative Analysis of Resident and Fellow Perspectives

Pavitt, Sara; Bogetz, Alyssa L.; Blankenburg, Rebecca

doi:10.1097/acm.0000000000002867

Cited by 10 publications

(13 citation statements)

References 19 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…9 Although studies have examined learning for trainees requesting consults, we found no literature describing learning for trainees performing consults. [10][11][12][13] To optimize learning during consults by modulating IL, EL, and GL, 8 researchers must first measure these components to understand the role of CL during consults. Then, educators can take steps to avoid trainee cognitive overload, thereby improving patient care and reducing errors.…”

Section: Discussionmentioning

confidence: 99%

“…Then, educators can take steps to avoid trainee cognitive overload, thereby improving patient care and reducing errors. 12,14 However, the most well-known CL measure, the Paas scale, 6 consists of a single item and thus functions unidimensionally. The Paas scale is, therefore, unlikely to capture the nuances of IL, EL, and GL during consults.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

The Cognitive Load of Inpatient Consults: Development of the Consult Cognitive Load Instrument and Initial Validity Evidence

et al. 2021

View full text Add to dashboard Cite

PurposeFellows and residents provide inpatient consultations. Though consults vary considerably, measuring the associated cognitive load (CL) is key to guiding faculty on how to optimize learning during consults. However, existing CL instruments, such as the unidimensional Paas scale, cannot separate the 3 components of CL and may miss the nuances of consult CL. Therefore, the authors developed the Consult Cognitive Load (CCL) instrument to measure the 3 CL components during consults. To provide a window into the vital yet underresearched consult learning environment and to improve training and patient care, we developed a multidimensional instrument to measure the mental effort associated with trainees completing inpatient consults.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The Cognitive Load of Inpatient Consults: Development of the Consult Cognitive Load Instrument and Initial Validity Evidence

et al. 2021

View full text Add to dashboard Cite

show abstract

“…Consulting subspecialists often contribute expertise vital to informing diagnosis, guiding management, or establishing outpatient follow-up. However, in some situations, consultation has unintended negative consequences, including unnecessary testing and outpatient follow-up, conflicting subspecialty recommendations, delays in care, patient and family dissatisfaction, and miscommunication between teams . A retrospective cohort study of more than 700 000 admissions among adult Medicare beneficiaries found higher health care resource use when consultations were performed, without mortality benefit .…”

Section: Introductionmentioning

confidence: 99%

“…However, in some situations, consultation has unintended negative consequences, including unnecessary testing and outpatient follow-up, 1 conflicting subspecialty recommendations, 2 delays in care, [3][4][5] patient and family dissatisfaction, 6 and miscommunication between teams. 7,8 A retrospective cohort study of more than 700 000 admissions among adult Medicare beneficiaries found higher health care resource use when consultations were performed, without mortality benefit. 9 Studies of adult patients suggest significant subjectivity and variability in the extent of consultation utilization within and across hospitals.…”

Section: Introductionmentioning

confidence: 99%

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

et al. 2023

View full text Add to dashboard Cite

ImportanceSubspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices.ObjectivesTo identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians.Design, Setting, and ParticipantsThis retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children’s hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023.ExposuresPatient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics.Main Outcomes and MeasuresThe primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians.ResultsWe evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years’ attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P &lt; .001).Conclusions and RelevanceIn this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.

show abstract

“…The role of fellows as resident supervisors on inpatient subspecialty rotations is an example of a near-peer learning dynamic because fellows are “neither professional educators nor experts in a given field; they teach their peers or junior learners while they themselves continue to learn.” 3,4 Possible advantages of the near-peer learning dynamic include the increased comfort of learners in sharing areas of weakness and the ability of near-peer educators to detect learners who are having difficulty. 3 Although there has been significant focus on the fellow–resident interaction during subspecialty consultations, 5–9 a related but different near-peer learning dynamic, the same attention has not been paid to the role of fellow as resident supervisor on inpatient subspecialty rotations. Although fellows are expected to supervise residents, 2 they receive little training on how to be successful in this role, and unlike faculty 10 and senior residents, 11 for whom there is evidence to inform best supervisory practices, to our knowledge, no such data exist for fellows.…”

mentioning

confidence: 99%

Bridge Builders: A Qualitative Study of Fellows’ Successful Supervision of Residents

et al. 2022

View full text Add to dashboard Cite

Purpose Clinical fellows, those training to become subspecialists in a program certified by the Accreditation Council for Graduate Medical Education, supervise residents on inpatient subspecialty rotations. Unlike for supervising residents or for faculty, there is a paucity of literature describing fellows’ supervision of residents. The aim of this study was to understand residents’ and fellows’ perception of successful supervision of residents by fellows on inpatient subspecialty rotations to inform the development of curricula to support fellows as supervisors. Method Using grounded theory methodology, the authors held focus groups in May 2020 of pediatric residents and pediatric subspecialty fellows at Boston Children’s Hospital, Boston, Massachusetts. Focus groups were conducted until thematic saturation was achieved. Deidentified transcripts were independently coded by 2 authors. The author team consolidated the codes into themes and developed an interpretive model for fellows’ successful supervision of residents. Key results were confirmed via member checking. Results The authors conducted 4 resident focus groups, composed of 16 pediatric residents, and 4 fellow focus groups, composed of 13 pediatric subspecialty fellows. Participants perceived that fellows who provided successful resident supervision advanced residents’ professional growth and supported residents’ development along 5 “bridges”: (1) generalist to subspecialist, (2) trainee to autonomous practitioner, (3) individual to member of the interprofessional team, (4) emerging physician to patient-facing care provider, and (5) newcomer to engaged clinical learner. Fellows can further residents’ growth in these areas by demonstrating approachability, empathy, appreciation, and kindness. Conclusions As newcomers on inpatient subspecialty rotations, residents engage in legitimate peripheral participation. Fellows who are successful supervisors move residents toward full participation in their profession via the bridge model. The fellow-resident dynamic carries advantages of near-peer learning. Fellows can harness their role, subspecialty knowledge, and familiarity with the training environment to enhance resident supervision.

show abstract

What Makes the “Perfect” Inpatient Consultation? A Qualitative Analysis of Resident and Fellow Perspectives

Cited by 10 publications

References 19 publications

The Cognitive Load of Inpatient Consults: Development of the Consult Cognitive Load Instrument and Initial Validity Evidence

The Cognitive Load of Inpatient Consults: Development of the Consult Cognitive Load Instrument and Initial Validity Evidence

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

Bridge Builders: A Qualitative Study of Fellows’ Successful Supervision of Residents

Contact Info

Product

Resources

About