Abstract
Outpatient exam room presentations (OERPs) in resident continuity clinic (RCC) can operationalize competency-based medical education and enhance patient satisfaction. We aimed to assess current OERP use and OERP barriers by surveying internal medicine attendings prior to and following a 4-week pilot of OERPs in RCC. Twenty-six out of an eligible 35 attendings completed the pre-pilot survey. Twenty attendings participated in the pilot and completed the post-pilot surveys. On the pre-pilot survey, 65% (17/26) of participants reported never using OERPs. Attendings’ perception of learner discomfort with OERPs as somewhat of or a significant barrier significantly decreased from pre-pilot to post-pilot (96% (25/26) v. 65% (13/20), p = 0.03). Time, feedback, and sensitive topics were frequently rated as barriers on both the pre-pilot and post-pilot surveys. On the post-pilot survey, most participants reported patient discomfort with OERPs, attending physician discomfort with OERPs, difficulty writing attestations during OERPs, and difficulty teaching during OERPs were not barriers. Additionally, 45% (9/20) reported planning to use OERPs in the future. Despite benefits of OERPs, there are several barriers to OERPs that need to be addressed prior to more routine implementation in resident continuity clinic. Further research should focus on strategies for overcoming barriers and maximizing benefits of OERPs as well as developing a set of OERP best practices to support routine implementation in RCC.
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Keywords: Outpatient exam room presentation, Resident continuity clinic, Direct observation, Medical education, Bedside rounds
Introduction
Over the past several decades, inpatient and outpatient patient presentations have gradually moved away from the bedside to the hallway or conference room, leaving medical educators calling for a concerted effort to return to the bedside [1–6]. Outpatient exam room presentations (OERPs) create an opportunity to return to the bedside and to address several current issues in graduate medical education including increasing patient satisfaction, enhancing patient-centered care, and operationalizing competency-based education through direct observation [1–4]. Frequently, in resident continuity clinic (RCC), the resident assesses the patient independently, presents to the attending in a conference room, and then returns to the exam room with or without the attending to conclude the visit. For this study, we define an outpatient exam room presentation (OERP) as the resident’s presentation and subsequent discussion taking place inside the exam room (not the conference room) with the attending physician, resident physician, and patient all present.
Inpatient bedside presentations are frequently studied, and several studies have demonstrated high levels of patient satisfaction and patient preference for bedside presentations over hallway or conference room presentations [7–13]. In one study, 83% and 94% of patients indicated a preference for bedside presentations before and after a bedside rounding intervention, respectively [13]. Patients also perceived their physicians as more compassionate when they performed bedside rounds compared with hallway or conference room rounds [3]. There has been much less investigation into using the outpatient setting as a venue for bedside presentations [14–17].
The current, albeit limited, literature examining OERPs demonstrates patients prefer OERPs over conference room presentations. Patients indicate increased comfort from listening to the clinical discussion and spending more time with their doctor as benefits of OERPs [14–17]. Studies have also found, in general, a positive attitude among attendings participating in OERPs. In prior studies, attendings found patient care benefits of OERPs such as maximizing shared decision-making. Attendings found several medical education benefits of OERPs including role modeling bedside manner and providing feedback to the learner based on direct observation [14–17]. In one survey study, 9 out of 10 attendings agreed that exam room presentations provided a better opportunity to observe learner skill and provide corrective feedback compared with conference room presentations [16]. Learners’ opinions of OERPs are mixed with a study by Rogers et al. demonstrating an increasingly favorable attitude among learners with increasing exposure to OERPs [14–17]. Learner autonomy and learner discomfort are frequently identified barriers to OERPs; however, other barriers are not well-delineated in the existing literature [14–17].
Despite several benefits, we suspect OERPs are underutilized and rarely used as a precepting method during RCC. With this study, we aimed to quantify current usage of OERPs at our institution across three internal medicine RCC sites and to identify barriers to OERPs in RCC among internal medicine attendings. We hypothesized that < 25% of attendings were using OERPs in RCC. We hypothesized the most frequently reported barriers would be difficulty in preserving resident autonomy and logistical concerns including time, reviewing the electronic medical record (EMR), and writing an attending attestation.
Materials and Methods
All University of Pittsburgh internal medicine attendings who precept RCC at one of three sites (VA, university, or community hospital) were invited to participate in the study. Prior to the pilot, attendings were asked to complete a pre-pilot survey and subsequently invited to a 45-min OERP workshop. The workshop was led by the principal investigator (RV) and included a discussion of the background of OERPs, a video demonstration of an OERP, and a review of general bedside teaching tips from the medical education literature [2, 18–20]. Following the workshop, all attendings were emailed with the PowerPoint presentation and the principal investigator (RV) offered to review the workshop one on one with attendings who were unable to attend in person. After the resident completed their assessment of the patient, the recommended OERP workflow was as follows: (1) resident notifies attending they are ready to present and both return to the exam room, (2) resident or attending provides introductions and a brief explanation of the process to the patient, (3) resident presents the patient followed by input from the attending, (4) attending could leave the room allowing the resident to conclude the visit independently or they could directly observe the end of the visit. Patients were encouraged to correct the resident if they reported any misinformation. The attendings’ involvement could include verification of history or physical exam, teaching points, and/or shared decision-making with the patient.
After the workshop, participants were asked to try OERPs in RCC with a goal of performing OERPs once or twice per half-day of precepting during the following 4 weeks. Although participants received a suggested workflow, participants were not given a script to follow verbatim and there may have been individual variation with how OERPs were conducted. Participants received a weekly reminder email to trial OERPs during the 4-week pilot period. Following the pilot, participants were asked to complete a post-pilot survey.
The pre-pilot and post-pilot surveys were developed through a review of the existing literature and input from senior clinician–educators with expertise in survey development. Both surveys were further refined through pilot testing with a group of multidisciplinary clinician–educator and clinician–investigator fellows. The surveys inquired about demographics, OERP use, and OERP barriers and are available in Supplement 1. Barrier responses were recorded on a 3-point scale: not a barrier, somewhat of a barrier, or a significant barrier. Thirty-five attendings were invited to complete the pre-pilot and post-pilot surveys. Twenty-one attendings took part in the OERP workshop and 26 completed the pre-pilot survey (response rate 74%). Twenty-four attendings completed the post-pilot survey; however, 4 of these attendings reported not participating (did not perform OERPs) and were excluded from the analysis. Twenty participated in the pilot and completed the post-pilot survey (response rate 57%). We calculated descriptive statistics for all variables. Pre-pilot and post-pilot data were analyzed in aggregate using chi-square and Fisher’s exact tests, as pre-pilot and post-pilot surveys were not linked. All statistical analyses were performed using STATA version 14.1 (StataCorp, College Station, TX) assuming a significance level of α = 0.05, and no adjustments were made for multiplicity.
Survey data were collected using REDCAP from November to December 2016. Both surveys included an optional free response section for participants to make additional comments. Free response comments were analyzed and discussed by the study authors (RV, CS) until consensus was reached as to the theme or construct represented by each comment. The University of Pittsburgh Institutional Review Board approved an exemption status for this study on November 1, 2016 (IRB no.: PRO16060665).
Results
On the pre-pilot survey, 65% (17/26) reported never using OERPs and the remaining 35% (9/26) reported using OERPs less than a quarter of the time in RCC. Pre-pilot and post-pilot survey responses regarding demographic characteristics, pre-pilot OERP use, pilot OERP use, and future OERP use are reported in Table 1. In general, most of our sample was female, had been practicing as an attending physician for less than 5 years, and reported precepting RCC 1–2 half-days per week. During the pilot, 40% of attendings only tried OERPs once, while 60% performed OERPs more than once.
Table 1.
Pre-pilot and post-pilot survey demographic characteristics, pre-pilot OERP use, pilot OERP use, and future OERP use in resident continuity clinic among internal medicine attendings
| Characteristics or reported use | Pre-pilot number (%) of attendings (n = 26) | Post-pilot number (%) of attendings (n = 20) |
|---|---|---|
| Gender | ||
| Female | 19 (73%) | 16 (80%) |
| Male | 7 (27%) | 4 (20%) |
| Number of years as an attending physician | ||
| < 5 years | 15 (58%) | 13 (65%) |
| 5–19 years | 3 (12%) | 3 (15%) |
| ≥ 20 years | 8 (31%) | 4 (20%) |
| Number of half-days precepting resident clinic | ||
| 1–2 half-days/week | 22 (85%) | 16 (80%) |
| > 3 half-days/week | 4 (15%) | 4 (20%) |
| OERP use prior to the pilot | ||
| 0% of patient encounters | 17 (65%) | – |
| 1–25% of patient encounters | 9 (35%) | – |
| Number of OERPs performed during pilot | ||
| 1 | – | 8 (40%) |
| > 1 | – | 12 (60%) |
| Plan to use OERPs in the future | ||
| Yes | – | 9 (45%) |
| Not sure | – | 9(45%) |
| No | – | 2 (10%) |
Attendings’ perceptions of pre-pilot and post-pilot barriers to OERPs in RCC are reported in Table 2. For reporting purposes, we combined somewhat of a barrier and significant barrier responses. Attendings’ perception of learner discomfort with OERPs significantly decreased from pre-pilot to post-pilot (96% (25/26) v. 65% (13/20), p = 0.03). Perception of all potential barriers except for difficulty addressing sensitive topics decreased from pre-pilot to post-pilot but did not reach the level of statistical significance. On the pre-pilot and post-pilot surveys, 92% and 80%, respectively, of attendings rated resident continuity clinic being too busy to do OERPs as somewhat of or a significant barrier. Additionally, resident continuity clinic being too busy to do OERPs was the most frequently cited significant barrier on the pre-pilot (50%, 13/26) and post-pilot (40%, 8/20) surveys. On the post-pilot survey, 75% and 70% of attendings rated difficulty giving learners feedback during OERPs and difficulty addressing sensitive topics, respectively, as somewhat of or a significant barrier. On the pre-pilot survey, the majority of attendings rated patient discomfort with OERPs as not a barrier. On the post-pilot survey, the majority of attendings felt patient discomfort with OERPs, attending physician discomfort with OERPs, difficulty writing attestations during OERPs, and difficulty teaching during OERPs were not barriers. On the post-pilot survey, 45% (9/20) plan to use OERPs in the future, 45% (9/20) were unsure if they were going to use OERPs in the future, and 10% (2/10) planned to not use OERPs in the future.
Table 2.
Percent of internal medicine attendings reporting potential OERP barriers as somewhat of a barrier or a significant barrier on pre-pilot and post-pilot surveys
| Potential barriers | Pre-pilot survey (n = 26 attendings) | Post-pilot survey (n = 20 attendings) | p value |
|---|---|---|---|
| Patients are uncomfortable with exam room presentations. | 7 (27%) | 3 (15%) | 0.84 |
| Learners are uncomfortable with exam room presentations. | 25 (96%) | 13 (65%) | 0.03* |
| Attending physicians are uncomfortable with exam room presentations. | 16 (62%) | 9 (45%) | 0.18 |
| Resident continuity clinic is too busy to do exam room presentations. | 24 (92%) | 16 (80%) | 0.55 |
| Exam room presentations undermine the learner’s autonomy. | 18 (69%) | 11 (55%) | 0.65 |
| It is difficult to review the EMR during exam room presentations. | 21 (81%) | 12 (60%) | 0.21 |
| It is difficult to write my attending attestation during exam room presentations. | 14 (54%) | 7 (35%) | 0.48 |
| It is difficult to teach during exam room presentations. | 13 (50%) | 8 (40%) | 0.87 |
| It is difficult to give feedback to the learner during exam room presentations. | 20 (77%) | 15 (75%) | 0.67 |
| Sensitive topics are difficult to address with exam room presentations. | 18 (69%) | 14 (70%) | > 0.99 |
*Statistical significance, level of significance defined as < 0.05
Free response comments included both benefits and drawbacks of OERPs. Benefits reported in the free response section included patient enjoyment, direct observation of resident skills and informed formative feedback regarding history-taking skills, and physical exam maneuvers. Attendings also found that urgent care visits, cases with salient physical exam findings, and visits involving communication skills were well-suited for OERPs. Drawbacks of OERPs reported in the free response section included time constraints, especially difficulty in monitoring the flow of residents and difficulty in redirecting talkative patients. Other drawbacks included difficulty in reviewing the EMR and difficulty with discussions involving points of uncertainty, evidence-based medicine, or sensitive issues (i.e., mental health) during OERPs. Another sticking point was how to deliver constructive feedback to the resident during OERPs without damaging the resident–patient relationship. Selected quotations from the post-pilot survey free response section highlighting some of these advantages and disadvantages of OERPs are presented in Table 3.
Table 3.
Selected post-pilot survey attending free responses
| Topic | Outpatient exam room presentation cons | Outpatient exam room presentation pros |
|---|---|---|
| Case selection | “Difficult for cases where they [residents] want to talk about uncertainty and evidence… about pain or mental health.” |
“Want to target these bedside presentations to urgent care, help with difficult conversations and patients where physical exam is important in diagnosis/treatment decisions.” “I think urgent care presentations are ideal for several reasons… generally doesn’t require much chart review, less concerned about… resident forming relationships with the patients.” |
| Resident supervision | “I often catch things in the EMR that they miss while presenting (abnormal lab)… I really didn’t have time to look at the EMR the way I usually do.” | “I was able to fine tune history and exam skills with teaching points that I would not have been able to do as well without direct observations.” |
| Time concerns | “While I was in the room with the resident, I made teaching points that went beyond what I would do in the precepting room. I couldn’t see the flow of residents in the precepting room. When I returned after one session, there was a line of residents… waiting for me. I would have adjusted my teaching to be more efficient if I could see those residents.” | |
| Patient involvement | “… some patients are very chatty and like to be involved and are difficult to redirect which can make getting through the staffing in an organized fashion difficult.” | “I was surprised how easy it was. It was fun and the patient enjoyed it.” |
| Feedback | “…giving feedback in front of the patient is not ideal…” | “It was easy to give positive feedback in the room, but it was also fine to just give the corrective feedback when we left the room.” |
Discussion
In this study, we examined the frequency of OERPs in RCC at our institution and assessed internal medicine attendings’ perception of barriers to OERPs both before and after a pilot of OERPs in RCC. We found that prior to our pilot, the majority of attendings (65%) were never using OERPs. Attendings’ perception of learner discomfort with OERPs significantly decreased from pre-pilot to post-pilot and 45% indicated they were willing to use OERPs in the future.
Strengths of our study include this is the first study, to our knowledge, to assess the prevalence of OERPs in RCC. Additionally, the pilot took place across three independent RCC sites (VA, university, and community hospital). Study limitations include the following: limited generalizability as most participants were junior faculty female physicians, possible response bias, single institution design, study was limited to internal medicine, and infrequent use of OERPs among participating attendings. The small number of participants and unlinked surveys also necessitated analysis of data in aggregate. The survey did not inquire about participation in the OERP workshop or use of OERP workshop materials. Thus, it is unclear how many participants used this information either before, during, or after the pilot and how this material may have impacted their survey responses. Additionally, it is possible some survey items may reflect the difficult nature of the task, for example, giving feedback, rather than a barrier specific to OERPs. For survey items about the resident or patient experience, it is important to remember that these survey responses reflect attendings’ attitudes only as we did not survey residents or patients. Free response items provided additional insight into the barriers; however, these survey sections were optional and may be subject to response bias. We believe several of the barriers attendings discussed including difficulty in discussing uncertainty, sensitive issues and redirecting talkative patients create unique learning opportunities for attendings to role model how to handle these situations.
A positive correlation between the frequency of OERP use and favorable attitudes towards OERPs has previously been demonstrated [14]. We suspect more frequent use of OERPs or a longer pilot time may have resulted in a significant decrease in other perceived barriers. With regard to low uptake, we recognize that OERPs may not be an acceptable precepting style for all clinician–educators; however, a subset of attendings found OERPs to be a useful precepting model. We were encouraged that attendings were willing to try OERPs with a rather brief intervention, 45-min workshop, and that almost half of attendings planned to continue to use OERPs. With regard to the 45% of attendings who were unsure about future OERP use, we suspect further faculty development including highlighting benefits, strategizing solutions to barriers, and formulating best practices may help them routinely implement OERPs in RCC. For next steps, we plan to explore barriers and potential strategies for overcoming these barriers through qualitative interviews with attendings and residents that participate in OERPs. We ultimately aim to develop a set of OERP best practices to support routine use in RCC.
Conclusion
We believe OERPs are poised to play an important role in the changing landscape of graduate medical education including operationalizing patient satisfaction initiatives and competency-based education requirements; however, there are still several barriers that require further investigation before OERPs can be regularly incorporated into RCC. Future research should investigate best practices that address common barriers in order to integrate OERPs as a feasible and sustainable precepting model in RCC.
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Acknowledgments
The authors wish to thank Doris Rubio, PhD, who helped with statistical analyses for this project.
Funding
Funding was provided by the University of Pittsburgh Medical Center Shadyside Hospital and Shadyside Hospital Foundation Thomas H. Nimick Competitive Research Fund and The University of Pittsburgh Division of General Internal Medicine.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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