teaching, but not practicing, etiquette-based...

Teaching, But Not Practicing, Etiquette-Based

Medicine

Dr. Leonard Feldman

Disclosures- None

Objectives

•  Describe the concept of Etiquette-based Medicine (EtBM)•  Evaluate how frequently IM interns at Johns Hopkins Hospital

and Maryland practice EtBM•  Assess whether we need to increase EtBM practice among

interns and residents at Johns Hopkins•  Discuss how we can increase EtBM practice

A brief history of work hours reform

1984 Libby Zion case

1989 NYS Section 405

2003 ACGME adopts 80-hour workweek

2011 ACGME adopts 16-hour shift rule

1999 IOM publishes ‘To Err is Human’

ACGME Common Program Rule 2011

•  Limits continuous work hours for interns to 16 •  Mandates 10 hours off between shifts •  Increases supervision requirements •  Maintains 80-hour workweek •  Aim to reduce resident fatigue, improve patient safety

Key questions

•  How have work hour changes impacted… •  Patient care •  Education •  Practice •  Professionalism

•  Will today’s training produce competent physicians? •  Are changes to the current system needed?

In 2012, how are interns spending their time in the hospital

“For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context, and meaning to those interactions” --ACGME

Changing demands on intern time

•  Shorter continuous work periods as of 2011 •  Fewer hours per week in the hospital as of 2003 •  Widespread adoption of electronic medical record

Time motion study

Etiquette-based Medicine

•  “patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive.”

•  “medical education and postgraduate training should place more emphasis on this aspect of the doctor–patient relationship — what I would call “etiquette-based medicine.”

Kahn MW. Etiquette-based medicine. The New England journal of medicine. May 8 2008;358(19):1988-1989.


•  Kahn’s checklist of physician etiquette for the clinical encounter

1.  Ask permission to enter the room; wait for an answer. 2.  Introduce yourself, showing ID badge. 3.  Shake hands (wear glove if needed). 4.  Sit down. Smile if appropriate. 5.  Briefly explain your role on the team. 6.  Ask the patient how he or she is feeling about being in

the hospital.



•  Advantages of check list •  Clear •  Efficient to teach and evaluate •  Easy for trainees to practice •  Does not address the way the doctor feels •  Focuses on observable behaviors (milestones) •  Complement efforts to train physicians to be humane

•  May take priority over compassion-based medicine. •  Behavior provides the necessary foundation for the patient to

have a satisfying experience. •  Simpler to change behavior than attitudes •  Prioritize behavior over feeling •  Stress practice and mastery over character development


Kalamazoo Consensus Conference- 1999

•  Reviewed 5 models of doctor–patient communication described in the 1990’s

•  Through a long process, developed the 7 tasks•  7 essential sets of communication tasks:

1.  build the doctor–patient relationship2.  open the discussion3.  gather information4.  understand the patient’s perspective5.  share information6.  reach agreement on problems and plans7.  provide closure

Acad. Med. 2001;76:390–393.

Hopkins Medical School

Johns Hopkins Blackboard- 2014

Hopkins Medical School M1-M2

•  Teach to the checklist- patient-centered and relationship-centered paradigm

•  Assessments •  observed 40 minute patient interview •  4 station SP exam

•  Pass rate in the communication skills domain •  Very high, often 98%•  Average score in this domain over the past 3 years is

in the 88-93% range•  “Students completing CFM have a good sense of the

value of communication skills and use them”

Johns Hopkins SOM PRECEDE

•  Taught specifically about patient-centered interview techniques to maximize relationship and clinical reasoning •  empathy •  agenda setting •  open ended questions

•  Receive EtBM-based Feedback •  directly from SP's through 2 different encounters

•  EtBM covered in other settings •  bedside presentations and strategies for patient inclusion. •  discharge counseling in which involves patient-centered

communication strategies to maximize understanding and retention.

•  Bayview- "knock, touch, and tell" campaign •  focusing on etiquette

Methods - Setting

•  Setting •  PGY-1 residents in two internal medicine programs in

Baltimore during January, 2012 •  Total of 29 interns observed through call cycle

•  10 interns (21%) at site 1 •  19 interns (32%) at site 2

•  Survey of Hopkins interns 6 months later

Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? Journal of general internal medicine. Aug 2013;28(8):1042-1047

Methods - Sites

Site 1

• Large urban health system • 1051 beds • Modified overnight call • All notes electronic • Bedside rounds

• Large urban health system • 757 beds • Night float system • Daily progress notes on paper • Office rounds

Site 2


Methods - Observation

•  Observers •  22 trained Hopkins undergraduate students •  Orientation, hospital tour, sensitivity, HIPAA training

•  Observation tool •  Activities recorded on iPod Touch “TimeTracker” app •  Observers certified at 85% concordance rate with

researchers •  Quality control – 2 hours at each site


Definitions

Behavior Definition Introducing self Providing a name Introducing role Uses term “doctor”, “resident”, “intern”, or

“medical team” Sitting down Sitting on the bed, in a chair, or crouching if

no chair was available during at least part of the encounter

Touching the patient Any form of physical contact that occurred at least once during the encounter including shaking a patient’s hand, touching a patient on the shoulder, or performing any part of the physical exam.

Asked open-ended question Asked the patient any question that required more than a yes/no answer

Block L, Hutzler L, Habicht R, et al. Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter. Journal of hospital medicine. Nov 2013;8(11):631-634.

Intern Introductions

Total encounters N (%)

Introduced self

Introduced role

Overall 732 (100%) 40% 36% JHH 373 (51%) 35%*† 29%*† UMD 359 (49%) 45% 44% Male 284 (39%) 39% 35% Female 448 (61%) 41% 38% Day shift 551 (75%) 37%* 34%* Night shift 181 (25%) 48% 45% Admitting shift 377 (52%) 46%* 42%* Non-admitting shift 355 (48%) 34% 30% * p<0.05 in unadjusted bivariate analysis† p<0.05 in analysis adjusted for clustering at observer and intern levels

Touching Patients

Total encounters N (%)

Touched patient

Overall 732 (100%) 64% JHH 373 (51%) 62%* UMD 359 (49%) 69% Male 284 (39%) 64% Female 448 (61%) 67% Day shift 551 (75%) 65% Night shift 181 (25%) 67% Admitting shift 377 (52%) 63% Non-admitting shift 355 (48%) 69% Block L, Hutzler L, Habicht R, et al. Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter. Journal of hospital medicine. Nov 2013;8(11):631-634.

Sitting with Patients

Total encounters N (%) Sat down

Overall 732 (100%) 9% JHH 373 (51%) 10% UMD 359 (49%) 8% Male 284 (39%) 9% Female 448 (61%) 10% Day shift 551 (75%) 9% Night shift 181 (25%) 12% Admitting shift 377 (52%) 10% Non-admitting shift 355 (48%) 9% Block L, Hutzler L, Habicht R, et al. Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter. Journal of hospital medicine. Nov 2013;8(11):631-634.

Asked Open-Ended Question

Total encounters N (%) Open-Ended Question

Overall 732 (100%) 75% JHH 373 (51%) 70%* UMD 359 (49%) 81% Male 284 (39%) 74% Female 448 (61%) 76% Day shift 551 (75%) 77% Night shift 181 (25%) 71% Admitting shift 377 (52%) 75% Non-admitting shift 355 (48%) 76% Block L, Hutzler L, Habicht R, et al. Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter. Journal of hospital medicine. Nov 2013;8(11):631-634.

Perception vs. Reality

*p<0.01 comparing observed and reported values

Do we have a problem here?

Introducing yourself •  may improve patient satisfaction and acceptance of trainee

involvement in care •  only 10% of hospitalized patients in 1 study correctly

identified a physician on their inpatient team •  even during admitting shifts, when the first encounter with

a patient likely took place, interns introduced themselves during 46% of encounters

Francis JJ, Pankratz VS, Huddleston JM. Patient satisfaction associated with correct identification of physician’s photographs. Mayo Clin Proc. 2001;76:604–608.Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169:199–201.

Benefits of touch •  Reduces anxiety levels among patients and improve

compliance with treatment regimens •  66% of patients consider a physician’s touch comforting, •  58% believe it to be healing

Osmun WE, Brown JB, Stewart M, Graham S. Patients’ attitudes to comforting touch in family practice. Can Fam Physician. 2000;46: 2411–2416.

Sitting •  RCT found that most patients preferred a sitting physician •  Believed that practitioners who sat were more

compassionate and spent more time with them

Strasser F, Palmer JL, Williey J, et al. Impact of physician sitting versus standing during inpatient oncology consultations: patients’ preference and perception of compassion and duration. A randomized controlledtrial. J Pain Symptom Manage. 2005;29:489–497.

Is this just a Hopkins/Maryland problem?

Tackett S, Tad-Y D, Rios R, Kisuule F, Wright S. Appraising the practice of etiquette-based medicine in the inpatient setting. J Gen Intern Med. 2013;28(7):908–913.

No

Possible Solutions

•  Role modeling •  Provide chairs •  Face sheet

Solutions •  Face Sheets

Dudas R, Lemerman H, Barone M, Serwint J. PHACES (Photographs of academic clinicians and their educational status): a tool to improve delivery of family-centered care. Acad Pediatr. 2010;10:138–145.

Solutions

Dudas R, Lemerman H, Barone M, Serwint J. PHACES (Photographs of academic clinicians and their educational status): a tool to improve delivery of family-centered care. Acad Pediatr. 2010;10:138–145.

Solutions

Solutions

Included SW, CM, Pharmacist, PT, OT, SLP

Discharge

All patients did matching and pt satisfaction survey

Table 1 Table 1: Pa*ent Demographics

Parameter (Percent or Mean) Control (%) Intervention (%)

N 86 111 Age (years) 54.75 (18.57) 55.06 (16.18)

Female* 46 (53.49) 44 (39.64) Male* 40 (46.51) 67 (60.36)

White (non-Hispanic) 25 (29.07) 28 (25.22) Black 55 (63.95) 68 (61.26)

Other (including Hispanic) 6 (6.98) 15 (13.51) College Education 35 (40.70) 50 (45.04)

High School Education 45(52.32) 57(51.35) Less than High School Education 6 (7.0) 4 (3.6)

Length of Stay (days) Median, 4 Median, 4

Patient Survey Matching

Figure 2: Hospital Ra*ng and Subject Ability to Iden*fy Providers

8.54

3.3

0.6

8.79

4.8

2.7

0

1

2

3

4

5

6

7

8

9

10

Rating of Johns Hopkins Hospital Mean Photos Matched Mean Roles Matches

Control Intervention

*

*

*Statistically significant difference, p<0.05

Patient Survey

42

52 53

63 68 69

0

10

20

30

40

50

60

70

80

Percent of participants strongly agreeing with the statement: "different types of healthcare

providers enjoyed working with each other"


providers communicated well with each other"


providers worked together effectively to coordinate my care"

Control Intervention *

* *

Conclusions •  FACES sheets improved identification of healthcare team members

and roles

•  The FACES intervention patients more strongly perceived that providers worked cohesively as team and enjoyed working together

•  There was a non-significant trend towards improved patient satisfaction and patient perception of healthcare member teamwork in the intervention arm

•  There were no significant changes in the rates with which participants would recommend the Johns Hopkins Hospital to family members and friends

•  Too few patients recognize the individual members of the healthcare team working on their behalf

Acknowledgements

•  Lauren Block, MD, MPH •  Lindsey Hutzler •  Robert Habicht, MD •  Albert W. Wu, MD, MPH •  Kathryn Novello Silva, MD •  Timothy Niessen, MD, MPH •  Nora Oliver, MD

Acknowledgements

•  Osler Center for Clinical Excellence •  Hospitalist Scholars Fund

Historical time motion studies

1984 Libby Zion case

1989 NYS Section 405

2003 ACGME adopts 80-hour workweek

2011 ACGME adopts 16-hour shift rule

1999 IOM publishes ‘To Err is Human’

1961 First time motion study published

1971 First multi-department time motion study published

1988/1993 Lurie studies show more time spent documenting than with patients

1998-2000 Moore and Dresselhaus studies - time in activities of low education value

2011 Time study of hospitalists finds similar pattern of time allocation

2010 Fletcher- 12% of time in direct patient care

Hypothesis

Relative to historical studies,

More time Less time

• Handoffs • Accessing EMR • Using computers

• Direct patient care • Education • Sleeping

Methods - Outcomes Outcome Percent of time in Activities Primary Direct patient care Admitting patients

Follow-up care Family meetings

Secondary Education Rounds Teaching Conferences

Indirect patient care

Notes Orders Paperwork Handoffs Calling consultants

Miscellaneous Eating Sleeping Walking


Methods – Data analysis

•  Percent of time in each activity aggregated •  Overlapping time (multitasking) assigned to activity more

closely related to patient care •  Simple and mixed level regression analysis

•  Adjust for clustering at intern, observer level


Results - Time allocation

12.3%

14.7%

63.6%

9.3%

Patient care Education Indirect pt care Misc


Results – Time by activity and site

Total Site 1 Site 2 Total time (hours) 873 439 (50.3%) 434 (49.7%) Direct patient care 12.3% 11.4% 13.3%* Initial patient evaluation 3.8% 3.6% 4.1% Follow-up patient visit 7.2% 6.5% 7.8%*+ Family meeting 0.5% 0.4% 0.6% Procedures 0.7% 0.9% 0.6% Education 14.7% 18.8% 10.6%* Educational conferences 2.3% 2.8% 1.8% Reading about medicine 2.1% 2.8% 1.3%*+ Rounds 9.7% 12.2% 7.3%*+ Indirect patient care 63.6% 61.2% 66.1%* Reviewing patient chart 14.5% 14.7% 14.3% Writing notes 16.1% 13.1% 19.1% Talking with providers 20% 20.5% 19.5% Paperwork 3.8% 1.5% 6.1%*+ Writing orders 6.4% 7.3% 5.4% Handoffs 2.9% 4% 1.7%*+ Miscellaneous 9.3% 8.6% 10% Eating, sleeping, & social 3.3% 3.5% 3.2% Walking 5.9% 5% 6.8%*

*p<0.05 in unadjusted analysis + p<0.05 in adjusted analysis

<1% of time in patient education, teaching students, patient transport, procedure consent

Results - Time spent per patient

Overall Site 1 Site 2

Per patient overall Minutes (range)

7.7 (0-39.6)

7.3 (0.3-39.6)

8 (0-16.3)

Per new admission Minutes (range)

16.6 (4.4-54.5)

20.6 (10.2-54.5)

13.6 (4.4-33.3)


Results - Comparison to historical studies

*

*

* * * *

* *

*

*

*

*

*


Conclusions

•  Minority of time in direct patient care •  Two thirds of time in indirect patient care

•  40% of time in front of the computer •  More time reviewing charts than seeing patients •  20% of time spent discussing cases

•  Similar findings between two sites •  Call system did not impact patient care time


Conclusions

Relative to historical studies,

More time Less time

• Computers • Handoffs • Discussion

• Direct patient care • Eating & sleeping

Conclusions

Patient care 1.8 hours

Indirect patient care 9.6 hours

Misc 1.4 hours

Education 2.2 hours

On a typical 15-hour day, how is time allocated?


Limitations

•  External validity •  Measurement error

•  Using non-medical observers •  Re-allocation of time spent multitasking

•  Hawthorne effect •  Work outside of hospital setting not observed •  Did not assess quality of interactions or patient

perspectives


Implications for residents

•  Interns today can expect less face-to-face time with patients •  Increasing time constraints – 80-hour workweek, 16-

hour shifts •  Increasing demands – educational activities,

communication with large teams, documentation •  Activities of low educational value reduced

•  Less eating, sleeping, transport, and phlebotomy

à Will this impact patient-doctor relationship and quality of care?

References 1.  Iglehart JK. Revisiting duty-hour limits – IOM recommendations for patient safety and

resident education. New Engl J Med. 2008 Dec 18. 359(25):2632-35. 2.  Drolet BC, Spalluto LB, Fischer SA. Residents’ perspectives on ACGME regulation of

supervision and duty hours – A national survey. New Engl J Med. 2010 Dec 1; e34:1-4. 3.  Antiel RM, Thompson SM, Reed DA, et al. ACGME duty-hour recommendations – A

national survey of residency program directors. New Engl J Med. 2010 Aug 4; e12:1-6. 4.  Antiel RM, Thompson SM, Hafferty FW, et al. Duty hour recommendations and implications

for meeting the ACGME core competencies: Views of residency directors. May Clin Proc. 2011 Mar: 86(3):185-91.

5.  McCoy CP, Halvorsen AJ, Loftus CG, et al. Effect of 16-hour duty periods of patient care and resident education. Mayo Clin Proc. 2011; 86(3): 192-6.

6.  Schuh LA, Khan MA, Harle H. Pilot trial of IOM duty hour recommendations in neurology residency programs: Unintended consequences. Neurology. 2011; 77: 883-7.

7.  Volpp KG, Friedman W, Romano PS, et al. Residency training at a crossroads: Duty-hour standards 2010. Ann Int Med. 2010; 153: 826-8.

8.  Papp KK, Stoller EP, Sage P, et al. The effects of sleep loss and fatigue on resident-physicians: A multi-institutional, mixed-method study. Acad Med. 2004; 79(5): 394-406.

9.  West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011; 306(9): 952-960.

References 10. Ripp J, Babyatsky M, Fallar R. The incidence and predictors of job burnout in first-

year internal medicine residents: A five-institution study. Acad Med. 2011; 86: 1304-10.

11. West CP, Tan AF, Habermann TM. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009; 302(12): 1294-1300.

12. Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Int Med. 2002; 136(5): 358-67.

13. Prins JT, Gazendam-Donofrio SM, Tubben BJ. Burnout in medical resident: A review. Med Educ. 2007; 41: 788-800.

14. Ripp J, Fallar R, Babyatsky M, et al. Prevalence of resident burnout at the start of training. Teach and Learn in Med. 2010; 22(3): 172-5.

15. Gottein L, Shanafelt TD, Wipf JE. The effects of work hours limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Int Med. 2005; 165:2601-06.

16. Gopal R, Glasheen JJ, Miyoshi TJ. Burnout and internal medicine resident work-hour restriction. Arch Int Med. 2005; 165: 2595-600.

17. Fletcher KE, Reed DA, Arora VM. Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules. J Gen Int Med. 2011; 26(8): 907-19.

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