Improving Medical Training for the Care of Chronic Conditions

• Evaluate the impact of SMAs on residents' and medical students' confidence, attitudes, comfort and beliefs regarding chronic care issues and management of diabetes compared to other ambulatory training experiences. [ Time Frame: 4 Months ] [ Designated as safety issue: No ]
  

• To assess the feasibility of using direct observation to accurately measure and compare time utilization patterns and diabetes management issues covered by trainees during patient encounters, and to identify how traditional encounters with patients with [ Time Frame: 6 months ] [ Designated as safety issue: No ]
  

: Most physicians receive training in and about an acute care-oriented health care system that cannot adequately address the challenges of chronic care management. While medical training has increasingly included chronic care management, quality care necessitates education approaches that go farther. In April 2005, the Louis Stokes Cleveland VAMC implemented a weekly Diabetes Shared Medical Appointment (SMA). Our recently published initial results (based on 44 SMA participants and 35 comparison patients) indicated that SMAs based on the chronic care model are effective in improving glycemic and blood pressure control in patients who are at high risk for cardiovascular morbidity including those previously labeled "non-compliant" or "non-adherent." (1) Updated information for 334 patients documented a mean change in A1c of -.9 (+/- 1.9), p<.001. The pre-SMA mean for this group was 9 (+/- 2.1) and the post-SMA was 8.4 (+/- 1.7). Thus, results from the SMAs are sustained and, as such, SMAs offer an important opportunity to improve chronic care and a unique setting for training physicians. SMAs offer the potential to provide training in crucial skills that have to date remained less amendable to traditional educational practices. In order to equip physicians with resources to effectively and efficiently manage chronic care, the ways in which SMA experiences are processed and integrated into learning about interdisciplinary approaches and expanding trainees' understanding of chronic care issues need to be examined. Without addressing this gap, it is not possible to develop a comprehensive care model that links education and patient outcomes for chronic conditions, such as diabetes. Our aims will help define relevant parameters to assess ways SMAs impact on beliefs, attitudes, and the processes and content of encounters regarding chronic condition and interdisciplinary care for patients with diabetes. Building on previous pilot work, we will continue to address evaluating and validating instruments to inform a larger grant application. The proposed pilot project includes using a think-aloud protocol to evaluate and validate new items and scales assessing interdisciplinary team and chronic care/diabetes beliefs, and evaluating and adjusting direct observation coding tools for chronic condition care.