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Inspired by the ABIM Foundation's Choosing Wisely® campaign, the "Things We Do for No Reason™" (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

Leading inpatient teams is a foundational clinical responsibility of resident physicians and leadership is a core competency for inpatient physicians, yet few training programs have formal leadership curricula to realize this clinical skill.We implemented a 4-module curriculum for PGY1 internal medicine residents. The program focused on the managerial skills necessary for daily clinical leadership, followed by clinical coaching. Interns were first introduced to foundational concepts and then given the opportunity to apply those concepts to real-world practice followed by clinical coaching.Using direct-observations and a previously published checklist for rounds leadership, this study sought to evaluate the workplace behavior change for novice residents leading inpatient teams for the first time. We conducted a prospective cohort study (March 2016 and August 2018) of internal medicine residents at a large tertiary academic medical center in Boston, MA. Trained faculty raters performed direct observations of clinical rounding experiences using the checklist and compared the findings to historical and internal controls. Questionnaires were distributed pre- and post- curriculum to assess satisfaction and readiness to lead a team.We trained 65 PGY1 residents and raters conducted 140 direct observations - 36 in the intervention group and 104 among historical controls. The unadjusted mean score in rounds leadership skills for the intervention group was 19.0 (A formal curriculum to train residents as leaders led to behavior change in the workplace in domains essential to rounds leadership. We also found that the curriculum was highly regarded in that all interns indicated they would recommend the curriculum to a peer. Moreover, the program may have assuaged some anxiety during the transition to junior year as 90% of interns surveyed felt more ready to start PGY2 year than historical trainings. We learned that while a robust, multi-faceted modular curriculum and clinical coaching successfully resulted in behavior change, the resources required to manage this program are significant and difficult to sustain. Future iterations could include asynchronous material and potentially peer-observation of rounds leadership to reduce the burden on faculty and program curricular time.

ObjectivesHospitalists are expected to be competent in performing bedside procedures, which are associated with significant morbidity and mortality. A national decline in procedures performed by hospitalists has prompted questions about their procedural competency. Additionally, though simulation-based mastery learning (SBML) has been shown to be effective among trainees whether this approach has enduring benefits for independent practitioners who already have experience is unknown. We aimed to assess the baseline procedural skill of hospitalists already credentialed to perform procedures. We hypothesised that simulation-based training of hospitalists would result in durable skill gains after several months.DesignProspective cohort study with pretraining and post-training measurements.SettingSingle, large, urban academic medical centre in the USA.ParticipantsTwenty-two out of 38 eligible participants defined as hospitalists working on teaching services where they would supervise trainees performing procedures.InterventionsOne-on-one, 60 min SBML of lumbar puncture (LP) and abdominal paracentesis (AP).Primary and secondary outcome measuresOur primary outcome was the percentage of hospitalists obtaining minimum passing scores (MPS) on LP and AP checklists; our secondary outcomes were average checklist scores and self-reported confidence.ResultsAt baseline, only 16% hospitalists met or exceeded the MPS for LP and 32% for AP. Immediately after SBML, 100% of hospitalists reached this threshold. Reassessment an average of 7 months later revealed that only 40% of hospitalists achieved the MPS. Confidence increased initially after training but declined over time.ConclusionsHospitalists may be performing invasive bedside procedures without demonstration of adequate skill. A single evidence-based training intervention was insufficient to sustain skills for the majority of hospitalists over a short period of time. More stringent practices for certifying hospitalists who perform risky procedures are warranted, as well as mechanisms to support skill maintenance, such as periodic simulation-based training and assessment.

Background Developing teaching skills is a fundamental part of physician postgraduate training. Although resident-as-teacher curricula are proliferating, there is no clear consensus on how best to train resident physicians as clinical teachers. Peer observation has been shown to be effective in other settings, including faculty development, and could be adopted for resident teaching skill development. Methods The authors developed a 5-day resident-as-teacher training programme, founded on three principles: (i) focused seminars; (ii) authentic teaching experiences; and (iii) peer observation. To provide genuine teaching experiences, course participants taught regularly scheduled curricular sessions. Residents were partnered with a peer; each delivered two teaching sessions and provided two peer observations. Results Evaluations revealed the course had a 'major impact' on participants' teaching. Significant improvements were observed in self-reported comfort and confidence with teaching and in providing feedback. Peer observation was cited as the most effective component of the course. Nearly all residents were both comfortable receiving and providing peer-observed feedback. A majority of residents reported that they were more likely to seek feedback as a result of the course. The faculty member time required was limited to 1-2 hours per individual. Discussion Peer observation can be used effectively to engage residents and advance clinical teaching skills. Residents were generally comfortable giving and receiving feedback in peer-observer dyads. Employing peer observation also reduced the amount of faculty member time needed to deliver resident-as-teacher programming, thereby facilitating the scalability of the programme. Allowing participants to teach during regular conference time allowed for smooth integration into the pre-existing schedule for the training programme.

Background: Teaching subspecialty care to trainees who are not pursuing that subspecialty poses many challenges. These challenges are amplified in the teaching of oncology to non-oncologists because there are more new therapies emerging in oncology than in any other discipline, and there are few oncologic issues managed by generalists without consultation. Concurrently, there is an increasing need for generalists to manage many aspects of care for patients with cancer.Aim: To provide 12 tips for oncologists to use to educate trainees on their oncology rotations.Method: The tips provided are based upon the available literature and the authors' own experience.Results: The 12 tips presented offer specific strategies for oncologists to enhance their teaching by selection of appropriate content and enhancing delivery. Focus is placed on aspects of oncology that trainees are likely to encounter as a generalist or non-cancer subspecialist. While oncology is used as the case study, these strategies are adaptable to any subspecialty area.Conclusion: Oncologists and other subspecialists can be core medical educators.

Issue: Life-long learning is a skill that is central to competent health professionals, and medical educators have sought to understand how adult professionals learn, adapt to new information, and independently seek to learn more. Accrediting bodies now mandate that training programs teach in ways that promote self-directed learning (SDL) but do not provide adequate guidance on how to address this requirement. Evidence: The model for the SDL mandate in physician training is based mostly on early childhood and secondary education evidence and literature, and may not capture the unique environment of medical training and clinical education. Furthermore, there is uncertainty about how medical schools and postgraduate training programs should implement and evaluate SDL educational interventions. The Shapiro Institute for Education and Research, in conjunction with the Association of American Medical Colleges, convened teams from eight medical schools from North America to address the challenge of defining, implementing, and evaluating SDL and the structures needed to nurture and support its development in health professional training. Implications: In this commentary, the authors describe SDL in Medical Education, (SDL-ME), which is a construct of learning and pedagogy specific to medical students and physicians in training. SDL-ME builds on the foundations of SDL and self-regulated learning theory, but is specifically contextualized for the unique responsibilities of physicians to patients, inter-professional teams, and society. Through consensus, the authors offer suggestions for training programs to teach and evaluate SDL-ME. To teach self-directed learning requires placing the construct in the context of patient care and of an obligation to society at large. The SDL-ME construct builds upon SDL and SRL frameworks and suggests SDL as foundational to health professional identity formation.KEYWORDSself-directed learning; graduate medical education; undergraduate medical education; theoretical frameworksSupplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1938074 .

Background Consistent classification of consult requests may lead to more efficient and collegial conversations about patient care, which could improve work satisfaction and enhance the learning environment. The authors propose a framework of 7 consultation types (Table 1). We aimed to obtain validity evidence for this rubric to consistently classify consultation requests. Table 1. Framework for classifying consults into 7 types Methods A randomly selected sample of 100 de-identified infectious diseases (ID) consult requests from a single academic center were independently coded as 1 of the 7 consultation types by 3 ID specialists and 3 hospitalists. Perfect concordance (6/6 coders) and partial concordance (4/6 or 5/6 coders) was calculated. Total (3/3 coders) and partial (2/3 coders) concordance based on consult subtypes and provider specialty was also calculated. We compared proportions between groups using a chi square test. Results Perfect concordance was 30%, and partial concordance was 60% (Figure 1). Total concordance among ID specialists was 44% and among hospitalists was 54% (Table 2). In cases without perfect concordance (n=70), ID specialists had 20% total concordance and 70% partial concordance, while hospitalists had 34% total concordance and 59% partial concordance. ID specialists were less likely than hospitalists to have perfect concordance for ideal consults (52% vs 73%, P=0.01). ID specialists and hospitalists were similarly likely to classify a consult as ideal (65% vs 69%, P=0.34), but ID specialists were more likely to classify a consult as S.O.S. (25% vs. 17%, p=0.02), and less likely to classify a consult as confirmatory (3% vs 7%, P=0.02) (Table 3). Figure 1. Concordance overall by consensus consult type among hospitalists and infectious disease specialists Table 2. Concordance by consult type stratified among infectious disease specialists and hospitalists Table 3. Consult type by physician subspecialty, among infectious disease specialists and hospitalists Conclusion ID consults can be classified into a novel rubric of 7 subtypes. Overall, partial or perfect concordance between hospitalists and ID consultants was 90%. ID specialists were more likely to classify consult requests as S.O.S than hospitalists, and hospitalists were more likely to classify consults as confirmatory. Opportunities exist to utilize the rubric to improve provider communication and interprofessional education. Disclosures All Authors: No reported disclosures

BACKGROUND: Few generalists engage in basic science research or feel comfortable teaching physiology at the bedside. This may reflect a lack of understanding or confidence teaching physiologic principles. AIM: To inspire general internists to relearn and teach physiology in clinical practice. SETTING: An active biomedical research laboratory. PARTICIPANTS: We educated 67 faculty participants (4 primary care, 59 hospitalists, and 4 other specialties) from 24 medical centers, representing 17 states. PROGRAM DESCRIPTION: The 5-day course was structured around re-learning basic physiology principles and developing teaching skills. Participants engaged in hands-on experiments through 4 modules using aquatic species, each paired with a physiology content primer. Participants also developed teaching scripts based on their experiments. PROGRAM EVALUATION: Post-course surveys revealed that 97% felt confident teaching physiology at the bedside, 100% felt the course enhanced their understanding of the mechanisms of disease, and there was a significant improvement in self-reported teaching ability. DISCUSSION: An immersive, hands-on faculty development course that integrated physiology with clinical decision-making increased participants’ comfort level and self-rated ability to teach and incorporate physiology in their clinical work. We believe faculty development is one potential solution to the growing chasm between clinicians and scientists in general medicine.

Background: A significant proportion of human communication is nonverbal. Although the fields of business and psychology have significant literature on effectively using body language in a variety of situations, there is limited literature on effective body language for medical educators.Aim: To provide 12 tips to highlight effective body language strategies and techniques for medical educators.Method: The tips provided are based on our experiences and reflections as clinician-educators and the available literature.Results: The 12 tips presented offer specific strategies to engage learners, balance learner participation, and bring energy and passion to teaching.Conclusions: Medical educators seeking to maximize their effectiveness would benefit from an understanding of how body language affects a learning environment and how body language techniques can be used to engage audiences, maintain attention, control challenging learners, and convey passion for a topic. Understanding and using body langua...

Background: Consistent classification of consult requests may lead to more productive, efficient, and collegial conversations about patient care, which can facilitate improved work satisfaction and an enhanced learning environment. We propose an organizing framework of 7 specific consultation types: ideal, obligatory, procedural, S.O.S., confirmatory, inappropriate, and curbside. We aimed to obtain validity evidence for this rubric to consistently classify consultation requests in an academic setting. Methods: A random sample of 100 de-identified hematology oncology consultation requests made through the online consult portal from a single academic center were selected and independently coded as 1 of the 7 consultation types by 3 hematologists and 3 hospitalists. Perfect (same consult assignment by all coders) and partial (same consult assignment by >4/6 coders) concordance was calculated. Perfect and partial (>2/3 coders) inter-rater concordance based on consult subtypes and provider specialty was also calculated. To assess if length of consult request has an impact on the classification of consult, the length of the request was compared across concordant, partially concordant, and discordant requests. Results: Of the 100 consults, perfect concordance was 57%, and partial concordance was 92% (Figure 1). Perfect concordance was 69% amongst hematologists and 78% amongst hospitalists. In cases without perfect concordance (n=43), hematologists agreed with each other 76% of the time, while hospitalists agreed with each other 81% of the time. Of the consults that at least 4 coders classified in the same way, hospitalists were more likely than hematologists to have perfect concordance for ideal consults (89% vs. 66%, respectively; P=0.001) but less likely to have perfect concordance for S.O.S consults (56% vs. 100%, respectively; P=0.003). Hematologists were twice more likely than hospitalists to classify a consult request as S.O.S (26.7% vs. 12.3%, P Conclusion: Hematology oncology consult requests can be classified into a novel rubric of 7 specific subtypes. Overall, partial concordance between primary providers and consultants was high, and perfect concordance was moderate. Hematologists were more likely to classify consult requests as S.O.S (without specific questions) than primary providers. Opportunities exist to utilize the rubric to improve communication between health care providers and to improve the medical education of trainees. Disclosures No relevant conflicts of interest to declare.

BACKGROUND: In the context of inpatient general medicine, “rounding” refers to the process of seeing, assessing, and caring for patients as a team. The clinical leadership skills required of residents to lead rounds are essential to inpatient care and clinical education. Assessment of these skills has relevance to developing competent physicians; however, there is an absence of widely accepted tools to specifically measure this competency. OBJECTIVE: To develop and collect validity evidence for a direct observation instrument of internal medicine residents’ leadership skills during daily inpatient care rounds for future formative assessment. DESIGN: Prospective observational study. PARTICIPANTS: PGY2 and PGY3 internal medicine residents. MAIN MEASURES: The authors collected inferences of validity evidence according to Kane’s validity model. They performed direct observations of PGY2 and PGY3 residents by individual faculty and trained raters and measured inter-rater reliability, using the kappa statistic. Mixed linear regression models were used to compare PGY2 and PGY3 residents. Surveys captured faculty perceptions about value of the instrument. KEY RESULTS: A total of 223 observations were performed in 92 unique individuals. Twenty-four faculty used the observation instrument, of which 18 (75%) completed the post-survey, and 100% agreed that the instrument represented the resident’s global leadership abilities. Inter-rater reliability was strong, with an overall kappa statistic equaling 0.82. The mean performance for PGY2 and PGY3 residents was 15.9 (SD 5.1) and 17.7 (SD 4.1), respectively. Adjusting for repeated measures, there was no statistically significant difference between groups. CONCLUSIONS: The authors reported evidence for all four stages of validity and use of the instrument in clinical practice. Their work provides a codification of best practices of rounding leadership, which directly impacts the education of trainees, care of hospitalized patients, and use for formative assessment. The instrument also has the potential to be used for summative assessment.

Consultation amongst providers is a foundation of modern health care and one of the most frequent means of interdisciplinary communication. Accordingly, clear and efficient communication between providers and across medical specialties during consultation is essential to patient care and a collegial work environment. Traditionally, consultation requests are felt to require a clear question that falls within the purview of the consultant's expertise. However, this narrow constraint is often lacking in the real-world clinical environment and may in fact be detrimental to physician communication and patient care. In this Perspective, the authors propose an organizing framework of seven specific consultation types, which apply broadly across disciplines: ideal, obligatory, procedural, S.O.S., confirmatory, inappropriate, and curbside. The authors describe what factors define each type and the benefits and pitfalls of each. The proposed framework may help providers have more productive, efficient, and collegial conversations about patient care, which may facilitate improved work satisfaction and an enhanced learning environment.

Burnout in graduate medical education is pervasive and has a deleterious impact on career satisfaction, personal well-being, and patient outcomes. Interventions in residency programs have often addressed isolated contributors to burnout; however, a more comprehensive framework for conceptualizing wellness is needed.In this article the authors propose Maslow's hierarchy of human needs (physiologic, safety, love/belonging, esteem, and self-actualization) as a potential framework for addressing wellness initiatives. There are numerous contributors to burnout among physician-trainees, and programs to combat burnout must be equally multifaceted. A holistic approach, considering both the trainees personal and professional needs, is recommended. Maslow's Needs can be adapted to create such a framework in graduate medical education. The authors review current evidence to support this model.This work surveys current interventions to mitigate burnout and organizes them into a scaffold that can be used by residency programs interested in a complete framework to supporting wellness.

Background In cases where patients are unable to provide informed consent and have no surrogate decisionmaker, a hospital must seek guardian appointment as a legally recognized surrogate decision-maker. Objective The aim of this study was to examine the magnitudes of length of stay (LOS) beyond medical clearance and healthcare costs among patients referred for guardianship. Design, setting, patients This was a retrospective cohort study of all 61 adult inpatients in a single tertiary care hospital requiring guardianship between October 1, 2014, and September 30, 2015, matched with up to 3 controls from the same discharging services and hospitalized for at least as long as the date of clearance for referred patients. Measurements The following parameters were measured using generalized estimating equations: total LOS, LOS beyond medical clearance (excess LOS), medical complications, and total charges among referred patients, and the LOS and costs were compared with those of matched controls. Results Mean LOS for patients requiring guardianship was 31 ± 2 days, and the total charges averaged $179,243 ± 22,950. We documented 12 hospital-acquired complications in 10 (16%; 95% confidence interval [CI], 8%-28%) unique patients. Accounting for potential confounders, the process of obtaining guardianship was associated with a 37% longer total LOS (95% CI [12%- 67%]; P = .002), 58% higher excess LOS (95% CI [2%- 145%]; P = .04), and 23% higher total charges (95% CI [4%-46%]; P = .02). Conclusions In this single-center cohort study, the guardianship process was associated with prolonged hospital stay and higher total hospital charges even when compared with matched controls. Furthermore, one in six patients suffered from a hospital-associated complication after medical clearance.

Resident physicians routinely perform bedside procedures that pose substantial risk to patients. However, no standard programmatic approach to supervision and procedural competency assessment among residents currently exists. The authors performed a national survey of internal medicine (IM) program directors to examine procedural assessment and supervision practices of IM residency programs. Procedures chosen were those commonly performed by medicine residents at the bedside. Of the 368 IM programs, 226 (61%) completed the survey. Programs reported the predominant method of training as 171 (74%) apprenticeship and 106 (46%) as module based. The majority of programs used direct observation to attest to competence, with 55% to 62% relying on credentialed residents. Most programs also relied on a minimum number of procedures to determine competence (64%-88%), 72% of which reported 5 procedures (a lapsed historical standard). This national survey demonstrates that procedural assessment practices for IM residents are insufficiently robust and may put patients at undue risk.

Novel approaches for faculty development and assessment of procedural teaching skills are needed to improve the procedural education of trainees. The Objective Structured Teaching Exercise (OSTE) entails a simulated encounter in which faculty are observed teaching a standardized student and has been used to evaluate teaching skills. Use of an OSTE to assess the teaching of central venous catheterization has not been reported.The purpose of this study was to develop a procedural OSTE for subclavian central venous catheter (CVC) insertion and to determine specific aspects of procedural teaching associated with improved skills in novices.Critical care faculty/fellows taught a standardized student to insert a CVC in a simulator. We assessed the instructor's teaching skills using rating scales to generate a procedural teaching score. After this encounter, the instructor taught novice medical students to place CVCs in simulators. Novices then independently placed catheters in simulators and were evaluated by trained observers using a checklist. Generalized estimating equations were used to examine the correlation between specific teaching behaviors and the novices' skills in CVC placement.We recruited 10 participants to serve as teachers and 30 preclinical medical students to serve as novice learners. The overall mean procedural teaching score was 85.5 (±15.4). Improved student performance was directly related to the degree to which the teacher "provided positive feedback" (β = 1.53, SE = 0.44, P = 0.001), "offered learner suggestions for improvement" (β = 1.40, SE = 0.35, P 0.001), and "demonstrated the procedure in a step-by-step manner" (β = 2.50, SE = 0.45, P 0.001). There was no significant correlation between total scores and student skills (β = 0.06, SE = 0.46, P = 0.18).The OSTE is a standardized method to assess procedural teaching skills. Our findings suggest that specific aspects of procedural teaching should be emphasized to ensure effective transfer of psychomotor skills to trainees.