Academic Medicine

What Makes the "Perfect" Inpatient Consultation? A Qualitative Analysis of Resident and Fellow Perspectives Purpose: To characterize the methods of inpatient consult communication, given new communication modalities; to explore residents' and fellows' perspectives on the ideal consult and how this affects their teaching, learning, and patient safety; and to identify barriers to and strategies for optimizing consultations. Method: Using qualitative grounded theory, the authors conducted semistructured focus groups with pediatric residents and fellows at Lucile Packard Children's Hospital at Stanford University from October 2016 to September 2017, using questions developed by expert consensus to address study objectives. Sessions were audio recorded and transcribed verbatim. Two authors independently coded the transcripts and reconciled codes to develop categories and themes using constant comparison. The third author validated the codes, categories, and themes. To ensure trustworthiness, participants edited the themes for accuracy. Results: Twenty-seven residents and 16 fellows participated in seven focus groups (three with residents, four with fellows). Four themes emerged: (1) many forms of communication are successfully used for initial inpatient consult recommendations (in person, phone, text messages, notes in electronic medical records); (2) residents and fellows prefer in-person communication for consults, believing it leads to improved teaching, learning, and patient safety; (3) multiple strategies can optimize consults regardless of communication modality; (4) how residents request the initial consult affects the interaction and can increase fellow engagement, which leads to more fellow teaching, resident's improved understanding, and better patient care. Conclusions: Residents and fellows believe that structured initial consults conducted in person improve teaching, learning, and patient care. Several strategies exist to optimize this process. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A708. Acknowledgments: This work could not have been completed without the help of the Stanford Medicine Pediatric Medical Education Scholarly Concentration group. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: The project received IRB approval through the Stanford University review committee. Previous presentations: The abstract was presented at the Pediatric Academic Societies 2018 meeting and the Association of Pediatric Program Directors 2018 spring meeting. Correspondence should be addressed to Sara Pavitt, Department of Pediatrics, Stanford School of Medicine, 725 Welch Road, MC 5906, Palo Alto, CA 94304; telephone: (650) 497-8979; email: Scady@stanford.edu. © 2019 by the Association of American Medical Colleges

Fostering Meaning in Residency to Curb the Epidemic of Resident Burnout: Recommendations From Four Chief Medical Residents Burnout has become commonplace in residency training, affecting more than half of residents and having negative implications for both their well-being and their ability to care for patients. During the authors' year as chief medical residents at Brigham and Women's Hospital in 2017-2018, they became intimately familiar with the burnout epidemic in residency training. The authors argue that addressing resident burnout requires residency programs and teaching hospitals to focus not on the individual contributors to burnout, but instead on fostering meaning within residency to help residents find purpose and professional satisfaction in their work. In this Perspective, they highlight four important elements of residency that provide meaning: patient care, intellectual engagement, respect, and community. Patient care, intellectual engagement, and community provide residents with a focus that is larger than themselves, while respect is necessary for a resident's sense of belonging. The authors provide examples from their own experiences and from the literature to suggest ways in which residency programs and teaching hospitals can strengthen each of these elements within residency and curb the epidemic of burnout. The authors have informed the journal that they agree that David D. Berg, Sanjay Divakaran, Robert M. Stern, and Lindsay N. Warner all completed the intellectual and other work typical of the first author. Acknowledgments: The authors would like to thank Dr. Joel T. Katz and Dr. Joseph Loscalzo for their mentorship and review of the manuscript. Funding/Support: D.D. Berg is supported by a T32 postdoctoral training grant from the National Heart, Lung, and Blood Institute (T32 HL007604). S. Divakaran is supported by a T32 postdoctoral training grant from the National Heart, Lung, and Blood Institute (T32 HL094301). Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: Brigham and Women's Hospital Medical Grand Rounds; June 1, 2018; Boston, Massachusetts. Correspondence should be addressed to Robert M. Stern, Dana Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02115; telephone: 617-732-3779; email: Robert_Stern@dfci.harvard.edu. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 by the Association of American Medical Colleges

Learners as Leaders: A Global Groundswell of Students Leading Choosing Wisely Initiatives in Medical Education Resource stewardship and reducing low-value care have emerged as urgent priorities for health care delivery systems worldwide. However, few medical school curricula include adequate content to allow learners to master the knowledge, skills, and attitudes needed to contribute to this transformation toward value-based health care. This article describes a program to launch student-led curriculum enhancement initiatives in 7 countries. The program, called STARS (Students and Trainees Advocating for Resource Stewardship), was inspired by Choosing Wisely, a campaign by the American Board of Internal Medicine Foundation that seeks to promote conversations on avoiding unnecessary medical tests, treatments, and procedures. The initial STARS model, which originated in Canada in 2015, included a leadership summit, where students from multiple medical schools learned about Choosing Wisely principles, leadership, and advocacy. These students then led grassroots efforts at their local medical schools with faculty and other students to raise awareness and advocate for changes related to resource stewardship. Student-led efforts resulted in the integration of Choosing Wisely principles into case-based learning, the creation of student interest groups and electives, the launch of social media campaigns, and the organization of special presentations by local experts. The rapid spread of similar programs in 6 other countries (Italy, Japan, the Netherlands, New Zealand, Norway, and the United States) by 2018 suggests that STARS resonates across multiple settings and signals the potential for such a model to advance other important areas in medical education. This article documents results and lessons learned from the first 4 years of the program. The authors have informed the journal that they agree that both Karen B. Born and Christopher Moriates completed the intellectual and other work typical of the first author. Acknowledgments: The authors thank the students and faculty across the world engaged in Choosing Wisely STARS programs for their contributions to the STARS model. Funding/Support: Choosing Wisely Canada STARS was funded by an ABIM Foundation education grant. The U.S. Choosing Wisely STARS program was funded by grants from the ABIM Foundation and the Josiah Macy Jr. Foundation. Other disclosures: None reported. Ethical approval: Choosing Wisely STARS was approved by the University of Texas Institutional Review Board in 2017. The University of Toronto Research Ethics Board approved of this study in June 2018. Previous presentations: Choosing Wisely STARS U.S. was presented during poster presentations at the 2018 High Value Practice Academic Alliance national meeting, September 2018, Baltimore, MD, and Learn Serve Lead 2018: The AAMC Annual Meeting, November 2018, Austin, Texas. Correspondence should be addressed to Brian M. Wong, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room H466, Toronto, ON M4N 3M5, Canada; telephone: (416)480-6100, ext. 83709; email: BrianM.Wong@sunnybrook.ca; Twitter: @Brian_M_Wong. © 2019 by the Association of American Medical Colleges

Supporting New Physicians and New Parents: A Call to Create A Standard Parental Leave Policy for Residents Parents taking leave after the birth of a child is associated with significant benefits for infants, mothers, and fathers. Although nearly 40% of residents have or plan to have children during residency, there is no standard parental leave policy for these trainees. In this Perspective, the authors discuss the benefits of parental leave, synthesize findings about maternity bias and other negative effects of the current variable approaches to parental leave during residency, and explore underlying causes of the lack of a standard parental leave policy for residents. They also call on the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties to work together to address this issue, recommending a standard parental leave policy that ensures a minimum of eight weeks of paid leave for all residents without requiring them to extend training or becoming ineligible to sit for board certification exams. Creating evidence-based and family-friendly guidelines for parental leave is important to the progress of academic medicine in the modern era, as it supports parental and child health, promotes resident wellness, and reduces gender disparities in medicine to the benefit of all. Acknowledgements: The authors wish to thank Julie Oyler, MD, Lisa Willett, MD, and Angela Castellanos, MD, for their critical review of this article. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Anna Volerman, University of Chicago Medicine, 5841 South Maryland Ave, MC 2007, Chicago, IL 60637; telephone: (773) 702-6840; email: avolerman@uchicago.edu; Twitter: @annavolerman. © 2019 by the Association of American Medical Colleges

The Empirical Challenge of 21st Century Medical Education Medical education is at a crossroads. Facing challenges wrought by science and technology as well as societal change, the curriculum is increasingly out of synch with new needs in teaching content and medical practice. The path to significant curricular reform is difficult due to a variety of factors, including deeply entrenched values, the natural resistance to change, and the accreditation process. Indeed, even the very definition of what it means to be a professional is changing with profound implications for the future role of the physician and the sacrosanct doctor-patient relationship. In this Invited Commentary, the author enumerates challenges facing medical education in the current era. To address these challenges, the author recommends specific curricular emphases for 21st century medical education: knowledge capture and curation; collaboration with and management of artificial intelligence applications; a deep understanding of probabilistic reasoning; and the cultivation of empathy and compassion in accordance with ethical standards. Given these needs, it is imperative that schools act today to undertake significant curricular reform, and, in so doing, strive to make the hard changes necessary to produce optimal practitioners in a rapidly transforming 21st century. The author provides first steps an institution can take to begin to address these challenges. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: This Invited Commentary represents solely the views of the author. Previous presentations: This Invited Commentary is based on the 2019 Brodie Medical Education Award Lecture given by S.A. Wartman at the University of Virginia Medical School, Charlottesville, VA, February 27, 2019. Correspondence should be addressed to Steven A. Wartman, email: swartman@aahcdc.org. © 2019 by the Association of American Medical Colleges

Silent Night [Excerpt] Commentary on an Excerpt From Silent Night No abstract available

Invoking the Medical Humanities to Develop a #MedicineWeCanTrust Trust is a complex phenomenon that resists easy definition, but it is easily recognizable, or rather its absence is impossible to miss. The author draws inspiration from the #MedsWeCanTrust movement to advocate for #MedicineWeCanTrust. Trust can be seen as a "soft," "tender minded," optimistic condition fighting for survival in a "hard," "tough minded," jaundiced medicine. Modern medicine is traditionally patriarchal, individualistic, and resistant to encouraging democratic, collaborative habits as it socializes its young into hierarchical structures, or eats them whole. Yet trust is a health intervention and essential for the innovative expansion of medical culture as it encourages authentic democracy, interprofessional clinical teamwork, and patient-centeredness. Increases in trust lead to greater tolerance of uncertainty, one of the primary goals of medical education. Recent curriculum development work has shown that the medical humanities offer a superb delivery mechanism for ensuring democratic habits in medicine that align with social justice agendas, key to addressing links between social inequalities and compromised physical and mental health. Where lack of trust is associated with cynicism in doctors, increasing trust loosens dependence upon suffocating control mechanisms. This allows medicine to take on the moral concerns and uncertainties of an adulthood that also promises emotional warmth, guidance, support, and improved communication between colleagues and with patients. Medicine must embrace trust as the matrix of health care, and the medical humanities can educate for values such as tolerance of uncertainty and ambiguity as a basis to engendering trust. To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal's web site (https://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=65) follow the discussion on AM Rounds (academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type "New Conversations" (see Dr. Sklar's announcement of the current topic in the December 2018 issue for submission instructions and for more information about this feature). Editor's Note: This New Conversations contribution is part of the journal's ongoing conversation on trust in health care and health professions education. Acknowledgments: The author is grateful to Dr. Arno Kumagai for stimulating conversations on medical humanities and social justice issues. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Not applicable reported. Correspondence should be addressed to Alan Bleakley, Poldown Cottage, Escalls Cliff, Sennen, Penzance, Cornwall TR19 7BB United Kingdom; telephone: (+44) 1736-871797; e-mail: alan.bleakley@plymouth.ac.uk. © 2019 by the Association of American Medical Colleges

Collaborative Solutions to Antibiotic Stewardship in Small Community and Critical Access Hospitals The overuse and misuse of antibiotics affects patients in many ways, including by driving antibiotic resistance, a serious public health threat in the United States and around the world. To improve patient safety and address rising rates of resistance, an increasing number of health care facilities have created antibiotic stewardship programs (ASPs). ASPs have been successful in slowing the emergence of resistance and improving patient outcomes. However, there are serious geographic and resource barriers to ASP adoption in small community hospitals and critical access hospitals. Fortunately, many barriers can be overcome by using collaborative models to bring together key stakeholders, including large hospitals and health systems and academic medical centers; hospital associations; federal, state, and local public health organizations; and federal and state offices of rural health. These stakeholders are ideally positioned to assist with stewardship efforts in small community and critical access hospitals and, in doing so, can improve patient safety while stemming the spread of resistant bacteria. Acknowledgments: The authors acknowledge Elisa Arespacochaga for her support of the initiative. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the American Hospital Association, University of Illinois College of Law, the Centers for Disease Control and Prevention, the Federal Office of Rural Health Policy, or The Pew Charitable Trusts. Correspondence should be addressed to Jay Bhatt, 155 North Wacker Drive, Suite 400 Chicago, IL 60606; @bhangrajay: email: jbhatt@aha.org. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "work of the United States Government" for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2019 by the Association of American Medical Colleges

Professionalism as the Bedrock of High-Value Care "High-value care" has become a popular mantra and a call to action among health system leaders, policy makers, and educators who are advocating widespread practice changes to reduce costs, minimize overuse, and optimize outcomes in the United States. Regrettably, current research does not demonstrate significant progress in improving high-value care. Many investigators have looked to payment models, benefit design, and policy changes as the main levers to reduce low-value care delivery; thus, the prevailing approach to ensuring high-value care has been to identify and limit low-value services. This approach has a clear limitation: the number of identified low-value services has become too numerous for individual physicians to track. Using professionalism as a key driver of practice change presents an important opportunity to shift from a deficit-based reactive model to one that is proactive and uses the concepts of intrinsic motivation and medical stewardship to effect high-value care. Transforming aspirational values such as professionalism into actions that engage all physician stakeholders regardless of their position or influence, and regardless of system agility or payment structure, has the potential for bringing about real change. These concepts can be integrated into medical education, introduced early in training, and modeled by educators to drive long-term sustainable change. Physicians can, and should, embrace professionalism as the motivation for redesigning care. Payment reform incentives that align with their professional values should follow and encourage these efforts; that is, payment reform should not be the impetus for redesigning care. Funding/Support: None reported. Other disclosures: Christopher Moriates reports receiving royalties from McGraw-Hill for the textbook Understanding Value-Based Healthcare. Ethical approval: Reported as not applicable. Correspondence should be addressed to Leah M. Marcotte, Department of Medicine, University of Washington, 1107 NE 45th Street, Suite 355, Seattle, WA 98105; telephone: (206) 543-3163; email: leahmar@uw.edu; Twitter: @marcottl. © 2019 by the Association of American Medical Colleges

A Comparison of Costs: How California Teaching Hospitals Achieved Slower Growth Than Nonteaching Hospitals in Operating Room Costs From 2005 to 2014 Purpose: Historically, teaching hospitals have had higher costs than their nonteaching counterparts, introducing potential financial risk in value-based payment models. This study compared risk-adjusted operating room (OR) costs between teaching and nonteaching hospitals in California. Method: Using 2,992 financial statements from fiscal years (FYs) 2005–2014, the authors extracted data for OR total costs, components of direct costs, and indirect costs. Cross-sectional and longitudinal models estimated OR costs per minute of surgery by teaching status, ownership, case mix index, and geographic area. Results: The risk-adjusted cost was $9.44 per minute less in teaching than nonteaching hospitals in FY2014 (95% CI 3.03, 15.85, P = .004). Between FY2005 and FY2014, OR costs grew more slowly at teaching hospitals due to slower wage growth and indirect costs per minute (respectively, -$0.13 and -$0.77 per minute per year, P = .005 and P < .001). Hourly pay rose more at teaching hospitals ($0.26 per hour per year, P = .008), but was more than offset by slower full-time equivalents growth (-0.002 per 10,000 OR minutes per year, P = .001). Between FY2005 and FY2014, operative volume increased at teaching hospitals and decreased at nonteaching hospitals. Conclusions: By 2014, California teaching hospitals had lower OR costs per minute than nonteaching hospitals due to relative labor productivity gains and slower indirect cost growth. The latter likely resulted from a shift of volume from nonteaching to teaching facilities. These trends will help teaching hospitals compete under value-based models. Implications for patients and nonteaching hospitals warrant evaluation. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A702. Funding/Support: Christopher Childers is funded by AHRQ#F32HS025079. AHRQ had no role in the design or conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, approval of the manuscript; or decision to submit for publication. Other disclosures: None reported. Ethical approval: The UCLA Institutional Review Board determined that the study was not human subjects research. Previous presentations: This work was presented at the American College of Surgeons 104th Annual Clinical Congress, Scientific Forum, Boston, MA, October 22, 2018. Correspondence should be addressed to Christopher P. Childers, Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., CHS 72-247, Los Angeles, CA 90095; email: cchilders@mednet.ucla.edu; Twitter: @cchildersmd. © 2019 by the Association of American Medical Colleges

Alexandros Sfakianakis
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