#25 Turning Indirect Patient Care Activities into Teachable Moments

April 11, 2023 | By Molly Heublein

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with Danielle O’Toole, MD and Meredith Vanstone, PhD

Drs. Danielle O’Toole and Meredith Vanstone of McMaster University join us this week to talk about their recent publication Optimizing the Educational Value of Indirect Patient Care.  Indirect patient care activities (IPCAs) have been highlighted as a component of the hidden curriculum in medical education as well as a significant source of physician burnout. We discuss the importance of exposing trainees to the realities of IPCAs, reframing IPCAs as educational opportunities, and incorporating IPCAs into curriculum via Dr. O’Toole’s Five E’s.  

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Show Segments

• Intro, disclaimer, guest bio
• Guests one-liners
• Picks of the Week
• Indirect Patient Care Activities (IPCAs) and Burnout 
• Acknowledging Educational Value of IPCAs
• Basics of the study
• Surprising findings
• Identity as a learner vs apprentice
• A curriculum for IPCAs
• The 5Es
• Boundaries
• Take home points
• Outro

Indirect Patient Care Activities Pearls

1. Indirect Patient Care Activities (IPCAs) include documentation, updating electronic medical records, managing orders, reviewing results, prescribing medications, and completing paperwork, i.e. all the work done by providers to care for patients that is not done during a face-to-face visit.
2. The workload of IPCAs has been increasing and is a major source of trainee and physician burnout. 
3. IPCAs have not traditionally been given significant focus in residency training, even though this is a major part of a physician’s career.  Explicitly and intentionally teaching on IPCAs demonstrates their value.  “They respect what you inspect.”
4. Professional identity is important for learners’ acquisition of IPCAs.  Those in the student mindset are focused on passing the next exam and look at IPCAs as scut work.  Those in the apprentice mindset can see IPCAs as essential to their future careers and an important part of caring for patients.
5. Learners want and need more instruction on IPCAs.  Training programs should consider incorporating a curriculum like Dr O’Toole’s.

Best Practices for Teaching Indirect Patient Care Activities(IPCAs)

This episode discusses the 2022 publication Optimizing the Educational Value of Indirect Patient Care by Danielle O’Toole, Marina Sadik, Gabrielle Inglis, Justin Weresch, and Meredith Vanstone.

Indirect Patient Care Activities and Burnout

Indirect patient care activities (IPCAs) encompass all of the work performed outside of the exam room such as updating patient charts, completing forms, managing orders, and filling prescriptions, in contrast to direct patient care in which the physician is sitting face-to-face with the patient. Currently about 50% of physicians’ time is spent on IPCAs (as opposed to face-to-face work).

The workload of IPCAs has increased exponentially in recent years and has been implicated in resident and physician burnout.  Drs. O’Toole and Vanstone identified three major components contributing to the increase in workload:

1. Adoption of electronic medical records 
2. The shift in purpose of charting from communication between providers to defensive documentation for legal purposes (“i.e. note bloat”)
3. Technological developments, such as prescription refill requests from pharmacies and automatic email notifications
   

With the increase in time spent on IPCAs, there is less time available for providers to spend with patients which is often the meaningful work that initially attracted physicians to medicine.  IPCAs are not well appreciated during training, and after graduation providers find they are burdened with these non-reimbursable and less satisfying tasks, which can lead to dissatisfaction and fewer providers going into primary care  (Arndt 2017, Joukes 2018, Shanafelt 2016). 

Acknowledging the Educational Value – “They respect what you inspect”

IPCAs are still often a hidden curriculum.  Many providers complete IPCAs at home, providing the illusion to trainees that the majority of their workday is spent interacting with patients.  If we spend 100% of our time teaching around direct patient care, even though we are spending 50% of our time on IPCAs, it discourages learners from appreciating  IPCAs as important.  By incorporating IPCAs into EPAs and assessments and formally providing education about this, we are naming the existence and importance of IPCAs.  

Study Design

Drs. O’Toole and Vanstone et al’s study (referred to later as O’Toole et al) included current family medicine residents, early family medicine physicians (1-5 years in practice), and senior physicians.  They held focus groups to allow participants to discuss and express their thoughts around IPCAs.

Dr Vanstone outlined a few of the theoretical principles which helped shaped their research design:

Steven Billett’s Workplace Learning Theory highlights that students need to recognize opportunities for learning in order to actually learn and benefit from them (Billett 2001). This theory was utilized to study which learning opportunities were deemed valuable and what signals indicated value in certain experiences.  O’Toole et al found that trainees view IPCAs as scut work instead of learning opportunities.. 

The Constructivist Grounded Theory promotes thinking about how individuals experience, draw meaning, and choose to navigate a social world.  This approach is particularly useful in newer fields in which there is little current knowledge on the phenomenon of interest (Charmaz 2014).  For this study, O’Toole et al wanted to understand how learners make sense of IPCAs encountered during residency training. 

Surprising Findings

Dr. O’Toole was surprised by how much IPCAs seem to impact learners’ decisions about a future career path, with more learners turning away from primary care and choosing something with less IPCA time such as hospital medicine or emergency medicine, findings that are supported by other studies (Knight 2019).  

Dr. Vanstone was surprised that learners were not expecting to have these tasks as part of their careers or perform IPCAs  during their training. 

Teaching IPCAs

Professional Identity: Learner vs. Apprentice 

The transition of professional identity from a learner to practitioner is key in the perspective of IPCAs.  The student mindset is focused on passing exams and obtaining impressive evaluations while practitioners focus on advocating for patients and optimizing their practice.  In the data from O’Toole et al, learners with a student mindset regarded IPCAs very differently from those who approached this work as an apprentice. 

Skills around IPCAs are primarily focused on the art of logistics, i.e. management reasoning skills, not clinical reasoning skills that we think of as classically important skills for a “clinical expert”.  When residents are looking at themselves as learners who need to pass their exams, they de-prioritize these IPCA skills as these are not things tested on the boards.  Educators who invest less time on showing and teaching IPCAs deprioritize these valuable skills in the eyes of the learner.  If we want residents to see the value in IPCAs, we need to explicitly label these tasks as providing advocacy for our patients, quality care, and patient safety.  We need to teach, provide formal feedback, and assess IPCA skills to encourage residents to engage with and learn how to effectively perform IPCAs.

Creating a Curriculum

The field of IPCAs is very new, and there has not been much published around teaching IPCAs.  Dr. O’Toole, her colleague Dr. Amie Davis, and a group of stakeholders looked at which entrustable professional activities (EPAs) are linked with IPCAs and benchmarked these to the resident level of training and specific observable behaviors.

Dr O’Toole has rolled out a curriculum on IPCAs with a series of four sessions:

• Documentation: medical legal considerations, avoiding note bloat, efficiency, and resources depending on style (templates vs dictation)  
• Billing: learners receive quarterly reports with feedback
• Inbox management: managing the inbox in a sustainable way
• Wellness: including how to set boundaries, balance workload, and process mistakes 

A gradual introduction to IPCAs can help.  Start with charting and direct patient care for the first few months of intern year, then incorporate prescription refills..  Entering into the second year of residency, start thinking about how to address consult notes and proceed in a stepwise manner from there. 

The Five Es by Dr. O’Toole

 Dr O’Toole uses her 5Es  framework to provide explicit teaching to learners 

• Educate- specific teaching on a topic.  Ie, what is the ideal soap note, what are the medical legal requirements, and how do we keep it succinct.  This is the opportunity to label the learning experience!  It includes skills in patient safety, confidentiality, continuity, communication, prioritization, maintaining health records, acknowledging personal limits, etc. 
• Exemplify- the educator demonstrates to the learner through the process.  Ie, how do you approach a prescription refill- is the refill request on time?  Does the patient need to come in for reassessment?  Are there new contraindications to a refill?
• Exercise- use deliberate practice.  1. Set a specific learning goal. 2. Allow for repetition of a specific learning task. 3. Give specific and immediate feedback
• Encourage- give guidance and provide regular check-ins
• Evaluate- provide field notes or evaluations

Set boundaries

Learning to manage IPCAs sustainably includes setting boundaries- it’s ok to tell patients that it will take X days to fill out forms or a certain amount of time to fill prescriptions.  Set no show policies.  It’s ok to set your limits.  Model this for learners.

Take home points:

No one loves IPCAs, but they are not going away.  We can help train learners to complete them more efficiently and sustainably, but this issue cannot be solved through education alone.  True improvement in IPCA workload requires  health systems advocacy to restructure electronic medical records and reduce some of this burden.

The way that we complete IPCAs is an art and will change over time.  Try to see as many models as possible to learn what might work for best for you.

Citations

O’Toole D, Sadik M, Inglis G, Weresch J, Vanstone M. Optimising the educational value of indirect patient care. Med Educ. 2022 Dec;56(12):1214-1222. doi: 10.1111/medu.14921. Epub 2022 Aug 29. PMID: 35972822.

Links

1. Pick of the Week by Dr. Meredith Vanstone: Joan Didion’s The Year of Magical Thinking 

Goal

Listeners will explore best practices and challenges around teaching indirect patient care activities (IPCAs)  in medical education.

Learning objectives

After listening to this episode listeners will…

1. Define the scope, history, role, and challenges of IPCAs
2. Identify current challenges (and opportunities) to residents’ training on best practices for IPCAs
3. Recognize adjustments that can be made to help learners succeed in performing IPCAs

Disclosures

Drs. Meredith Vanstone and Danielle O’Toole report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Heublein M, Vanstone M, O’Toole D, Kryzhanovskaya E. “#25 Turning Indirect Patient Care Activities into Teachable Moments.” The Curbsiders Teach Podcast. https://thecurbsiders.com/teach 11 April 2023.