While medical training has increasingly included chronic care management, quality care necessitates education approaches that go farther. Shared medical appointments (SMAs), which are associated with sustained improved clinical outcomes, offer an important opportunity for training physicians. In order to equip physicians with needed resources to manage chronic care, it is important to examine the ways in which SMA experiences are processed and integrated into learning about interdisciplinary approaches and expanding trainees' understanding of chronic care issues. The proposed pilot project included using a think-aloud protocol to evaluate and validate new items (closed-ended and open-ended) and scales assessing interdisciplinary team and chronic care/diabetes beliefs, and evaluating direct observation coding tools.
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. To assess the feasibility of using direct observation to measure and compare time utilization and diabetes management issues.
Pre-post design with trainees completing structured questionnaires (closed-ended and open-ended items). In-depth post-only interviews (less than 30-minutes in length) using the think-aloud protocol to evaluate new items were conducted with randomly selected members from each group of participants. This method asked participants to dialogue about what they were thinking, focusing on, feeling and doing internally as they read the items and responded.
On average trainees in the intervention group observed/participated in 3.4 SMAS for patients with diabetes and 7.0 for other types of health conditions. Checking confirmed that the comparison sites did not conduct shared medical appointments that included simultaneous involvement of multiple disciplines and patients in a group setting at one time. Of the four sets of items to assess impact on interdisciplinary teamwork perceptions, significant differences were found on only one set: change scores were significantly different for the two groups on the three-item scale assessing confidence in ability to perform teamwork related aspects of care. In addition, the groups significantly differed in the predicted direction on only one of the five subscales from the Diabetes Attitude Scale: seriousness of type 2 diabetes. The intervention group's mean level increased (mean change of -.88) while the comparison group's decreased (mean change of 1.12). Results from the think-aloud method suggested that several items were vague, and thoughts/reactions to several items about patients challenges and teamwork brought up the theme of 'it all depends' (e.g., on the stage of the disease).
In order to improve quality care we provide to Veterans with chronic conditions it is essential that we understand all the ways that SMAs improve diabetes management, including through linking quality training to quality care. The findings from this pilot study helped identify conceptual areas where additional or other measures are needed before pursuing a larger undertaking. As such our next step is to develop merit and SDP applications to evaluate the links between quality training and quality care for chronic conditions.
- Watts SA, Gee J, O'Day ME, Schaub K, Lawrence R, Aron D, Kirsh S. Nurse practitioner-led multidisciplinary teams to improve chronic illness care: the unique strengths of nurse practitioners applied to shared medical appointments/group visits. Journal of The American Academy of Nurse Practitioners. 2009 Mar 1; 21(3):167-72.