Putting The Charter Into Practice

    In 2009 and 2011, through a partnership the Council of Medical Specialty Societies (CMSS), Putting the Charter into Practice (PCIP) grants were awarded to professional medical organizations, health systems/hospitals, academic medical centers and medical practices that were working to advance medical professionalism.

    Grantees were selected in conjunction with the CMSS and a consumer representative. Several of these projects served as the basis for larger initiatives, including the Choosing Wisely® campaign.

    2011 Grantees

    In 2011, the PCIP grants aimed to facilitate the development of innovative, emerging strategies to advance appropriate health care decision-making and stewardship of health care resources, one of the commitments of the Physician Charter. Recipients and their programs included:

    American College of Physicians – Stewardship of Resources Case Studies
    The American College of Physicians Center for Ethics and Professionalism developed two case studies focusing on physician decisions about resource allocation and stewardship. (subscription required):

    In post-session evaluations, 93 percent of those responding said that the stewardship of resources session “maybe” or “definitely” had increased their skills and 91 percent said that they will do something different following the session.

    Costs of Care – Teaching Value
    As a medical student, Neel Shah was frustrated by the inability to understand how the costs of medical decisions could impact patients and society. Subsequently, Dr. Shah founded Costs of Care, a Boston-based non-profit whose mission is to “transform American healthcare delivery by empowering patients and their caregivers to deflate medical bills.”

    Through its Teaching Value project, Costs of Care and educators at Harvard Medical School and the University of Chicago have created interactive, case-based video modules to facilitate reflective learning about stewardship of health care resources among medical students, residents and practicing physicians. The video modules center on the care of a fictional patient admitted to the emergency room and each scenario is coupled with a debriefing video that includes key teaching points, including how to communicate with patients about unnecessary care and reducing overused or misused tests and procedures.

    Johns Hopkins Bayview Medical Center: Aligning Physician Cardiac Enzyme-Ordering Behavior with Established Guidelines
    Johns Hopkins Bayview clinicians had a longstanding interest in stewardship of resources, as evidenced by the creation of Providers for Responsible Ordering (PRO), a Bayview physician group with a mission “to reduce laboratory and radiologic testing with no clinical utility or unfavorable risk/benefit ratio (i.e., waste).” Building on PRO’s efforts, Bayview researchers, in collaboration with practicing physicians, residents and medical students, developed an initiative to reduce the overutilization of cardiac enzyme panels, a commonly ordered diagnostic test. The initiative included:

    • Development and promotion of an evidence-based guideline for ordering of cardiac enzymes for diagnosis of acute coronary syndrome at Bayview;
    • Restructuring of the hospital’s computer provider order entry system to change provider ordering of cardiac enzyme testing; and
    • Generating cardiac enzyme ordering report cards for house staff and faculty physicians using guideline-based benchmarks. Low performers received coaching to reduce unnecessary ordering, and high performers were interviewed to identify best ordering practices.

    The project team presented preliminary results showing a 66 percent reduction in cardiac-enzyme ordering, with $1.3 million in savings.

    National Physicians Alliance (NPA): Putting a “Top Five” List into Practice
    In this follow-up effort to its 2009 Putting the Charter into Practice grant project, NPA developed provider and patient versions of videos demonstrating scenarios in which physicians discuss some of the tests and procedures featured in the lists, along with patient education materials.

    Residents and faculty at three practices received communication skills training, followed by a six-month period in which the recommendations in their respective specialties were put into practice. The project team then used chart audits to compare the pre-intervention and post-intervention rates at which the “Top 5” recommendations were followed.

    Through this project, the University of Minnesota’s Division of Pediatric Emergency Medicine developed and implemented evidence-based practice guidelines and electronic clinical decision support tools for common causes of pediatric emergency room visits such as acute gastroenteritis and suspected appendicitis, two childhood conditions for which physicians commonly do not adhere to practice guidelines.

    The project team also developed a website with its pediatric emergency medicine decision tools to enable other institutions to learn about the project and access the guidelines.

    2009 Grantees

    In 2009, PCIP grants were awarded to several organizations that developed initiatives to advance the professional values and behaviors articulated in the Physician Charter among practicing physicians. The 2009 grantees and their projects included:

    Cleveland Clinic – Increasing Empathic Behaviors of Staff Physicians through Reflective Writing
    To bolster physician empathy, Cleveland Clinic investigators developed a six-session reflective writing course. The investigators recruited 40 staff physicians, assigning 20 of them to an intervention group and 20 to a control group.

    The intervention group received course readings prior to each session and participated in reflective writing and sharing in groups of four to five physicians, along with a trained physician facilitator. Session topics included:

    • An introduction to reflective writing and narrative medicine;
    • The patient experience of pain and suffering;
    • Empathy across cultural barriers;
    • The use of literature in empathic understanding;
    • Empathic communication of treatment plans/health literacy; and
    • The use of mindfulness to improve both quality of care and empathic engagement in patient care.

    Upon completion of the course, the intervention group showed a statistically significant improvement in empathy compared to the control group, as measured by the Jefferson Scale of Empathy. Their findings were published in an International Journal of Medical Education article.

    Johns Hopkins Bayview – Readmissions: A Missed Learning Opportunity for Hospitalists
    Johns Hopkins Bayview researchers implemented a program to address the Physician Charter commitment to engage in quality improvement. As part of the program, house officers were notified about all readmitted patients who were under their care during their initial hospitalizations. They were then given the opportunity to participate in facilitated reflections on what factors contributed to the readmission.

    Twenty-seven hospitalists completed reflection exercises on their rehospitalized patients and also completed pre- and post- intervention surveys. The surveys showed statistically significant changes in behavior among participating hospitalists following the reflection activities, including:

    • An increased likelihood of contacting the primary care provider after discharge;
    • Usually or always conducting “teachbacks” (having patients explain their post-discharge instructions back to the hospitalist to assess their understanding); and
    • Usually or always communicating with the readmitting provider if the patient returned to the hospital.

    National Physicians Alliance – Promoting Good Stewardship in Clinical Practice
    To encourage physicians to act as responsible stewards of resources per the Physician Charter, the NPA convened working groups to develop “Top Five” lists for internal medicine, family medicine and pediatrics. The lists consisted of tests and procedures which are commonly used but may be unnecessary and/or cause harm. The lists underwent field testing with more than 200 practicing physicians to ensure that the recommendations were valid and relevant to everyday practice. The project and resulting lists were described in an Archives of Internal Medicine article and made available on NPA’s website.

    This project provided the model for the Choosing Wisely campaign.

    The Ohio State University – Putting the Physician Charter into Practice for Central Ohio Physicians
    The appreciative inquiry approach is based on the belief that focusing on positive examples of what works is a more powerful driver of change than focusing on problems. A project team from Mt. Carmel Health System, OhioHealth and The Ohio State University Wexner Medical Center combined appreciative inquiry and storytelling to collect stories of when local physicians felt they were at their best professionally, and shared these interviews through educational programming.

    The project engaged Ohio State University medical students in a summer project to conduct appreciative inquiry interviews with local physicians. The students then developed short audio recordings centered on seven themes that emerged during their interviews.

    Society of General Internal Medicine (SGIM) – Communicating about Professionalism
    Recognizing that good physician-patient communication is an essential aspect of medical professionalism, the SGIM produced a workshop on communication skills and professionalism. The workshop included videos and role-play training for physicians on:

    • Disclosure of a medical error;
    • Initiating conversations about palliative care; and
    • Discussing a perceived breach of confidentiality.

    Trained faculty members administered the workshops to more than 200 attendees at seven regional SGIM meetings, the 2010 national SGIM annual meeting and 2011 American College of Physicians annual meeting.
    The project leaders also used their project as the basis for a communications workshop that was incorporated into the ambulatory residency curriculum at the University of Massachusetts and Brown University. Results presented at the 2013 Association of Program Directors in Internal Medicine Annual Meeting showed that a large percentage of residents found the workshops useful and used the communication skills in their subsequent residency training.

    The University of Chicago – Improving On-Call Etiquette among Internal Medicine Residents in Chicago: A Multi-Center Collaborative
    While formal medical school and residency curricula may espouse the virtues of professionalism, the hidden curriculum of unspoken values and norms may encourage unprofessional behavior. With their Putting the Charter into Practice grant, researchers from The University of Chicago Medical Center, Northwestern Memorial Hospital and NorthShore University HealthSystem confronted the hidden curriculum and provided residents with tools to navigate challenging professional situations by developing and implementing a workshop series on unprofessional behavior.

    Three 60-minute workshops were offered to internal medicine and hospitalist residents and academic hospitalists across the three participating institutions. Participants viewed the videos and engaged in small- and large-group discussions led by faculty moderators using a moderator presentation, debriefing worksheets with an answer key, and a session evaluation.

    Two-thirds of participants reported an intent to change unprofessional behavior after attending the workshop. Further study results were presented in two Journal of Hospital Medicine articles, “Participation in unprofessional behaviors among hospitalists: A multicenter study” and “Promoting professionalism via a video-based educational workshop for academic hospitalists and housestaff.”
    The video teaching modules have also been incorporated into the Graduate Medical Education Orientation at The University of Chicago Pritzker School of Medicine.