S.P. Trivedi is co-director, Innovations in Media and Education Delivery and clinical instructor, Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts. The author was, when the study occurred, a population health fellow, New York University Grossman School of Medicine, New York, New York.
Z. Kopp is a second-year resident in internal medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California.
Acad Med. 2021 Jul 1;96(7):1043-1049. doi: 10.1097/ACM.0000000000003896.
To characterize residents' practices around hospital discharge communication and their exposure to transitions-of-care instruction in graduate medical education (GME).
In 2019, internal medicine residents at 7 academic medical centers completed a cross-sectional survey reporting the types of transitions-of-care instruction they experienced during GME training and the frequency with which they performed 6 key discharge communication practices. The authors calculated a mean discharge communication score for each resident, and, using multiple logistic regression, they analyzed the relationship between exposure to types of educational experiences and discharge communication practices residents reported they performed frequently (> 60% of time). The authors used content analysis to explore factors that motivated residents to change their discharge practices.
The response rate was 63.5% (613/966). Resident discharge communication practices varied. Notably, only 17.0% (n = 104) reported routinely asking patients to "teach-back" or explain their understanding of the discharge plans. The odds of frequently performing key discharge communication practices were greater if residents received instruction based on observation of and feedback regarding their communication (adjusted odds ratio 1.73; 95% confidence interval [CI], 1.07-2.81) or if they received explicit on-rounds teaching (adjusted OR 1.46; 95% CI, 1.04-2.23). In open-ended comments, residents reported that experiencing adverse patient events at some point in the postdischarge continuum was a major impetus for practice change.
This study exposes gaps in hospital discharge communication with patients, highlights the benefits of workplace-based instruction on discharge communication skills, and reveals the influence of adverse events as a source of hidden curricula. The results suggest that developing faculty to incorporate transitions-of-care instruction in their rounds teaching and integrating experiences across the postdischarge continuum into residents' education may foster physicians-in-training who are champions of effective transitions of care within the fragmented health care system.
描述住院患者出院沟通实践以及在住院医师规范化培训（GME）中接受过渡护理指导的情况。
2019 年，7 所学术医疗中心的内科住院医师完成了一项横断面调查，报告他们在 GME 培训中经历的过渡护理指导类型以及他们执行 6 项关键出院沟通实践的频率。作者为每位住院医师计算了出院沟通评分，并用多因素逻辑回归分析了他们报告经常执行的（>60%的时间）教育经验类型与出院沟通实践之间的关系。作者采用内容分析法探讨了促使住院医师改变其出院实践的因素。
应答率为 63.5%（613/966）。住院医师的出院沟通实践存在差异。值得注意的是，只有 17.0%（n=104）的住院医师报告常规要求患者“复述”或解释其对出院计划的理解。如果住院医师接受基于观察和反馈的沟通指导（调整后的优势比 1.73；95%置信区间[CI]，1.07-2.81）或接受明确的随诊教学（调整后的优势比 1.46；95%CI，1.04-2.23），则他们更有可能经常执行关键的出院沟通实践。在开放性评论中，住院医师报告在出院后连续体的某个时间点经历不良患者事件是促使实践改变的主要动力。
本研究揭示了患者出院沟通方面的差距，强调了基于工作场所的出院沟通技能培训的益处，并揭示了不良事件作为隐藏课程的来源的影响。研究结果表明，培养教员在其随诊教学中融入过渡护理指导，并将出院后连续体中的经验纳入住院医师教育，可能会培养出在碎片化的医疗体系中成为有效过渡护理的拥护者的受训医师。
