The U.S. health system is plagued by a stubborn duality. While aspiring physicians are often attracted to the profession by the promise of working with patients, many of them end up spending far too much time away from the bedside once they reach residency. This has implications for quality of care and physician well-being.
A webinar featuring guest authors from a supplement in the April issue of Academic Medicine examines how precision education can be applied at the residency program level to improve care and learning and reduce physician burnout.
The supplement was produced by the AMA ChangeMedEd® initiative as part of its new strategic focus on precision education—a personalized approach to medical students, residents, and physicians as they progress along the educational continuum and through their professional lives.
Bedside time is golden
“There's value to both patients and to providers in the time that we spend together, particularly in the time that we spend examining patients,” said Brian T. Garibaldi, MD, associate program director of the Osler Medical Residency Program at Johns Hopkins Medicine. Dr. Garibaldi co-wrote “Navigating the Landscape of Precision Education: Insights From On-the-Ground Initiatives,” which appears in the supplement.
“Some of the stress and burnout that we see, particularly amongst junior trainees and medical students, is related to the lack of fulfillment that people get from spending time in front of a computer and not spending time with patients,” he said.
This realization led to the creation of the Graduate Medical Education Laboratory, a collaboration between Johns Hopkins Medicine, Stanford University School of Medicine, the University of Alabama at Birmingham Heersink School of Medicine, and the Society of Bedside Medicine. The collaboration was largely funded by a grant from the AMA Reimagining Residency initiative.
The first thing the investigators did was to come up with a precise way of understanding how residents spend their time in the hospital. They used the existing Real-Time Location System, which was created to track the use of expensive equipment. Most members of the intern class wore tracking badges while they were at work.
What Dr. Garibaldi and his colleagues found was a revelation.
“Our trainees spent only about 13% of their time in patient rooms,” he said, noting that this was generally true throughout the year. First-year residents spent about one-third of their time in the physician workroom and almost one-quarter in the ward hall.
The upshot, however, was that “when we asked residents how much time they thought they spent at the bedside and how they felt about their jobs, there was a negative or an inverse relationship between how much time they thought they spent at the bedside and their Maslach burnout scores,” he said. “So the more time they felt they spent at the bedside, the less burned out they were, the more resilient they felt and the higher they scored on their integrative wellness. Time at the bedside clearly matters, and it impacts the way that you feel about your work.”
Learn how too little time at the bedside drives resident physician burnout.
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The physical exam as case in point
“If we want to try to relate how we feel about our work and how much time we spend with patients [performing] actual clinical skills, we need to directly measure those clinical skills,” Dr. Garibaldi said. He also noted that when researchers have looked at when errors are being made, roughly half of errors are made in the physical exam. “When you further parse out where those errors are being made in the exam, the most common error in the physical exam is simply that the physical exam was never performed.”
Inspired by summative assessments conducted in the U.K. in which all residents must pass an examination of real patients at the bedside in front of attending physicians, the Osler Medical Residency Program created a project to assess physical exam and communication skills. As part of the assessment, each resident examines a patient with a specific issue in front of two attending physicians who have already examined or taken a history from the patient.
Immediately following the encounter, the attendings give feedback to improve the resident’s skills. Each resident rotates through five stations where they encounter seven patients, six of whom have real findings on physical exam.
“If you plot physical exam technique compared to identifying signs, there's a positive and significant correlation, so technique matters,” Dr. Garibaldi said, citing data from the first 100 residents. “If you identify the right physical exam findings, you're much more likely to include the correct differential diagnosis on your list of differential diagnoses.”
But the project’s findings point to the need for longitudinal changes too.
“What's a little bit concerning is that there's actually a significant decrease over time in how people perform on this physical exam assessment,” Dr. Garibaldi said. “This reflects the current training environment, where we don't spend a lot of time doing direct observation and feedback of clinical skills at the bedside. Therefore, if you ask someone to do a reflex exam in June of their intern year, and they haven't done it since medical school, they're not going to be as good as someone who is asked to do that same assessment in September or October.”
Dr. Garibaldi’s presentation was preceded by a talk by Eric J. Warm, MD, director of the Internal Medicine Training Program at University of Cincinnati, on precision education implementation lessons for positive behavior change.
The webinar, “Precision Education in Medical Education: On-the-Ground Initiatives and Learnings,” is enduring material and designated by the AMA for a maximum of one AMA PRA Category 1 Credit™.
It is part of the AMA Ed Hub™, an online platform with high-quality CME and education that supports the professional development needs of physicians and other health professionals. With topics relevant to you, it also offers an easy, streamlined way to find, take, track and report educational activities.
Learn more about AMA CME accreditation.
