Patel Roshni, Marquis Timothy J, Cook Aliza, Gielissen Katherine
Yale University School of Medicine, New Haven, CT, USA.
Yale-New Haven Hospital, New Haven, CT, USA.
J Gen Intern Med. 2024 Feb;39(2):255-262. doi: 10.1007/s11606-023-08406-x. Epub 2023 Sep 12.
The Primary Care Exception (PCE) is a billing rule from the Centers for Medicare and Medicaid Services (CMS) that allows supervising physicians to bill for ambulatory care provided by a resident without their direct supervision. There has been increased focus on entrustment as a method to assess readiness for unsupervised practice.
To understand the factors influencing attending physicians' use of the PCE in ambulatory settings and identify common themes defining what motivates faculty preceptors to use the PCE.
This was a qualitative exploratory study. Participants were interviewed one-on-one using a semi-structured template informed by the entrustment literature. Analysis was conducted using a thematically framed, grounded theory-based approach to identify major themes and subthemes.
Twenty-seven internal medicine teaching faculty took part in a multi-institutional study representing four residency training programs across two academic medical centers in Connecticut.
Four predominant categories of themes influencing PCE use were identified: (1) clinical environment factors, (2) attending attitudes, (3) resident characteristics, and (4) patient attributes. An attending's "internal rules" drawn from prior experiences served as a significant driver of PCE non-use regardless of the trainee, patient, or clinical context. A common conflict existed between using the PCE to promote resident autonomy versus waiving the PCE to promote safety.
The PCE can serve as a tool to support resident autonomy, confidence, and overall clinical efficiency. Choice of PCE use by attendings involved complex internal decision-making schema balancing internal, patient, resident, and environmental-related factors. The lack of standardized processes in competency evaluation may increase susceptibility to biases, which could be mitigated by applying standardized modes of assessment that encompass shared principles.
初级保健例外（PCE）是医疗保险和医疗补助服务中心（CMS）的一项计费规则，允许指导医师为住院医师在无直接监督情况下提供的门诊护理计费。作为评估无监督实践准备情况的一种方法，委托受到了越来越多的关注。
了解影响主治医师在门诊环境中使用PCE的因素，并确定定义促使带教教师使用PCE的动机的共同主题。
这是一项定性探索性研究。采用基于委托文献的半结构化模板对参与者进行一对一访谈。使用基于主题框架的扎根理论方法进行分析，以确定主要主题和子主题。
27名内科教学教员参与了一项多机构研究，该研究代表了康涅狄格州两个学术医疗中心的四个住院医师培训项目。
确定了影响PCE使用的四个主要主题类别：（1）临床环境因素，（2）主治医师态度，（3）住院医师特征，以及（4）患者属性。无论受训者、患者或临床背景如何，主治医师从以往经验中得出的“内部规则”是不使用PCE的重要驱动因素。在使用PCE促进住院医师自主性与放弃PCE以促进安全性之间存在常见冲突。
PCE可作为支持住院医师自主性、信心和整体临床效率的工具。主治医师对PCE的使用选择涉及复杂的内部决策模式，需要平衡内部、患者、住院医师和环境相关因素。能力评估中缺乏标准化流程可能会增加偏差易感性，应用包含共同原则的标准化评估模式可减轻这种偏差。
