Dan Nguyen, MD
I think it’s time for family medicine to rock the boat. Family physicians, and especially family medicine residents, are uniquely qualified to promote quality improvement by standardizing patient care processes.
As a family medicine intern at an urban academic institution, these past 6 months have been a blur of rotations. Every 4 weeks, we start a new service and drink from a fire-hose of learning the intricacies of “how-to-be-a resident.” Our intern training is the most diverse; we rotate through inpatient services in OBGYN, pediatrics, family medicine, internal medicine, general surgery, intensive care, and the emergency department.
For inpatient services, there are common tasks that all residents perform. We answer pages, place admission orders, write progress notes, discharge patients, sign-out the patient lists, etc. We have access to the same electronic medical record, the same resources, and are unified by an academic institution.
What dawned on me is that every service seems to coordinate patient care completely differently. Every 4 weeks, I would re-learn how to do the same types of tasks but with different methodology. The most glaring disparities I noticed were in how different services handle transitions of care, especially patient sign-out.
Why does every service have different methods of achieving the same goal when we have nearly the same resources? Why isn’t there a standardized approach to sign-outs? The best answer I’ve received is, “Oh, that’s just how it’s done.”
Because family medicine trainees experience the full variability of sign-out among services, we are uniquely poised to help standardize the process. For example, resident sign-out varies widely. Some services are completely dependent on the EMR to generate information, others have a completely separate Excel spreadsheet, and the rest seem to use a combination of the two.
The tools that are used for sign-out directly influence the amount of information passed between the day/night teams and when services transition at the time of rotation change. Patient care is directly impacted by the quality of sign-outs. Several prospective and retrospective studies have demonstrated that poor quality sign-outs resulted in higher numbers of medical errors. Taking a step further, the notable I-PASS multi-center study established the correlation between a standardized oral and written sign-out with a 23% relative reduction in the incidence of preventable adverse events.1 The difficulty lies in designing a standard that is useable across different services because most residents are not required to immerse themselves in an area outside of their practice.
Family medicine residents are an untapped resource for truly understanding gaps and idiosyncrasies between services and improving the sign-out process across services in their respective institutions. Time and again, I’ve shared information I learned from a prior rotation to improve patient care processes on a subsequent rotation. By virtue of our training, family medicine physicians can effectively communicate between services to unify them and create a cultural shift.
Reference
- Starmer, A. J. (2015). Changes in Medical Errors with a Handoff Program. New England Journal of Medicine,372(5), 490-491. doi:10.1056/nejmc1414788
STFM Blog 
Sorry, I need to reply with a “way back when” story. I’m not referring to when I was a FP resident, of little current applicability as it was the 1970s, pre-computer days, but a mere decade and a half ago. If I’m almost losing you, I urge you to invest 3 minutes to read on.
About fifteen years ago, given that we were aware of the capacity of the electronic health record to embed protocols into our records and use, primitive by today’s standards, of computer enhanced prompts and reminder, to urge compliance track adherence with standard orders and protocols, we initiated in the residency clinic the US Preventive Care Taskforce recommendations about preventive care care tailored to the patient’s age.
We knew we had to change our culture so we added incentives (residents could win prizes through adherence to standards and faculty received modest bonuses), education at how to make use of the protocols, teamwork that involved nurses, social pressure by publicizing compliance, and regular audits.Over time, our preventive care compliance zoomed up. The final step that was added was a one month rotation in preventive medicine for the residents taught by one of our faculty. So, in answer to your question, compliance with protocol involves leadership to get standards adopted and enforced, a constant battle to undo silo based cultures and a proactive, incentive based strategy to address resistance to change.
The FM literature is full of excellent articles on adoption of standardized care. If you want to change a system, you have to address all of the issues mentioned in Roger’s excellent book written more than 20 years ago, “Diffusion of Innovation”, it worked way back then and still does now. Geoffrey
In family medicine we most need change agents and least need those who remain stagnant and unable to change the course of health access, primary care, and outcomes for most Americans. We fail in training and in family medicine workforce because we fail in selection and preparation in ways that training cannot address.
Potential medical students and others preparing for health and education careers should spend age 14 to 30 years working in their communities improving health, education, and local resources in their communities. They should be selected as nurses, public health officers, or family physicians based on their ability to reshape lives toward better health, education, situations, environments, and relationships.
These change agent areas in addition to service orientation and empathy cannot be trained during formal medical education just as medical education cannot shape training outcomes. As soon as humans become social and most interactive, their abilities to make a difference should be developed by opportunities to facilitate interactive development – starting age 14 for some and later in others. The Culture of Health that we most need to improve health outcomes, requires entirely different culture shaping the needed change agents.
Only preparation, selection, training, and payment design specific to health access within the context of local community, culture, and practice can address the basic needs of most Americans most behind as well as facilitating the higher primary care, community health, public health, child development, education, and similar functions.
When students are prepared and selected the ways that are best for most Americans, their thoughts and actions and reflections can reshape an entire nation. Lack of making a difference for decades indicates our continued failure by design.
I have learned the most from those with different backgrounds and those who have experienced different training, often self-engineered (rural, accelerated FM residents, older students or FM grads, previous nursing or public health, activist students and residents, qualitative researchers, faculty that practiced where needed before becoming faculty). At STFM, these were generally seen in the 5 or 10 minute presentations – not the big ticket areas. Much learning occurs when you meet with these individuals and learn from them, between sessions or during sessions. As with curricula, it is the extracurricular that can be most enlightening.
Sadly our nation learns the least from most Americans most behind – and fails them most by designs shaped by those who know them least. They are damaged by lack of awareness to some degree, but mostly by those who focus on “their version” of quality efforts not realizing that what they do is most damaging where outcomes are already worst. The fact that we tolerate Pay for Performance designs is most revealing.
The P4P designs lack evidence basis for health outcomes and have evidence basis for discrimination against providers who care for those most complex with lesser health and most in need of care. Those with different backgrounds, preparation, selection, training, and careers would never tolerate this. Leading a nation to change requires us to change who we are in ways that can help our graduates change others and an entire nation.