Social and behavioral sciences (SBS) have received increased attention in medical education and patient care as our health care system struggles to understand chronic disease management, evolving models of health care delivery, and widening health disparities.1,2 In the clinical setting, SBS research addresses how behavioral and social processes such as cognition, motivation, socioeconomic status, and social support predict or influence health outcomes or health risk factors. Integrating an SBS focus into medical practice includes core content in multiple areas: health-related behaviors (e.g., patient’s diet and clinician’s adherence to procedure guidelines), behavior change counseling (e.g., goal setting and shared problem solving), sociocultural factors (e.g., language and literacy), mind–body factors (e.g., stress and pain management), professionalism/ethics, and health policy and economics.1,2 Recent studies estimate that social and behavioral factors account for nearly 50% of premature morbidity and mortality,3,4 and ongoing changes to medical school admissions tests and core competencies designate SBS as essential to medical education and clinical care.2,5
Beyond particular content areas, SBS also plays a role in understanding the process of delivering patient-centered care and learner-centered education. Patient-centered care requires providers to elicit a patient’s sociocultural context and preferences and then engage in shared decision making.6,7 Social and behavioral factors inform basic processes such as empathy, communication, emotion regulation, and cognition. Similarly, learner-centered education requires educators to tailor instructional techniques for activated learners’ needs.8,9 Both patient- and learner-centered approaches yield superior outcomes when compared with provider-centered approaches.9–11
SBS medical education guidelines have been established through current milestone and competency frameworks1,2,12,13; however, little is known about pedagogies, content, and timing for SBS integration.14,15 While SBS training often focuses on ambulatory settings, an SBS focus remains equally important during inpatient care. Responsiveness to social variables may improve hospital performance in high-visibility quality metrics such as patient satisfaction, pain management, hospital length of stay, and readmission rates.16–18 On the contrary, inattention to SBS factors contributes to poor posthospitalization outcomes and frequent readmissions.19 For instance, nearly 20% of all Medicare patients are readmitted within 30 days because of failures in medical adherence, lost transitions of care, failure to understand a patient’s resources, and poor comprehension of discharge instructions.19
Attending rounds provide a powerful platform for teaching clinical competencies, modeling humanistic care,20,21 and highlighting the integral role of social and behavioral factors in optimizing patient outcomes. However, tension between patients’ and learners’ needs may surface during attending rounds. In the context of limited time, resources, and acute medical management, teams should ideally provide patient-centered care while concurrently providing learner-centered clinical teaching.22Figure 1 illustrates the interplay of these competing demands in shaping how SBS topics emerge during inpatient care and teaching. More specifically, competing demands during attending rounds may determine both the presence (quantity) and team response for SBS topics. While teachers must address both learner and patient needs, contextual or environmental factors (e.g., team size, patient census) may alter this balance. Learner- and patient-centered skills (i.e., the “process” boxes in Figure 1) directly influence what content is elicited from learners (e.g., rotation goals, learner needs) and patients (e.g., presenting symptoms, patient needs). Patient “content” directly influences what SBS topics emerge (quantity) and how they are handled by the team (team response). Teaching “content” such as rotation goals and learner needs similarly influences SBS topic quantity and team response—for instance, a teacher may be more likely to screen a patient for alcohol use and spend time teaching about brief interventions for alcohol if the learner has indicated this as an interest or need. Ultimately, this complex interplay of process, content, and contextual factors may explain how SBS topics emerge and are discussed during attending rounds.
In this study, we observed inpatient attending rounds for internal medicine (IM) and pediatrics (Peds). Our aim was to quantify SBS topic prevalence during patient care and to rate team response to any topic once introduced. We hypothesized that during attending rounds, services would vary in SBS topic prevalence and SBS topic responses, and that this variation might be related to differences in team performance in patient- and learner-centeredness, after controlling for demographic and contextual factors.
From February 2012 to June 2012, we conducted a cross-sectional observation study of inpatient attending rounds at two academic hospitals, Stanford University School of Medicine and the University of California, San Francisco, School of Medicine (UCSF). Paired observers accompanied rounding teams as they visited patients, recording the prevalence and team responses of SBS topics, and team leaders’ patient- and learner-centered behaviors. Medical teams eligible for this study included at least one resident or attending physician (trainer) and at least one medical student or intern (learner).21 We recruited teams by likelihood of learners (interns, medical students) present and rater availability. Attendings on eligible teams were contacted via e-mail to participate in the study. Participants were provided an institutional review board–approved information sheet describing the study as observations of “clinical teaching on ward rounds” but were not specifically told about the focus on SBS topics. Teams were assured that raters would not interfere with rounding activities and were asked to proceed normally. The institutional review boards at UCSF and Stanford Schools of Medicine certified the study as “exempt.” Participation was voluntary, and written informed consent was not required.
Codesheet development and rater training
As a multidisciplinary research team, we developed the codesheet and iteratively tested it for construct and face validity (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A233). SBS topics, as well as potential team responses, and patient- and learner-centered behavioral items as well as anchors were described in a detailed codebook.
We locally recruited three premedical students and two graduate students and trained them as raters, to be deployed in pairs. We used training videos of clinical reenactments during rater trainings to assure interrater reliability and agreement. Supervisors (J.S., S.B., and J.R.) periodically joined the raters during attending rounds and held weekly fidelity and calibration meetings.
Outcome variables and data collection
We identified 30 SBS topics a priori using pivotal SBS reports1,2 and a validated instrument identifying culturally competent clinical care.23 After an SBS topic was raised, we scored team responses as negative, neutral, or positive, where a negative response undermined or devalued the communication, a neutral response failed to further conversation, and a positive response explored or reinforced topic discussion. For each patient, raters documented SBS topics raised during rounds, by whom the topics were raised (team member or patient or family member), and the team’s response to each SBS topic discussion.
We identified five attributes of team leaders’ patient-centeredness from a validated communication scale24 and recent reports on patient-centered care.6,25 Patient-centered care included the following attributes: shows care (treats patient with dignity and engages patient), elicits information (explores patient’s circumstances to provide better care), educates patient (checks for understanding regularly), and appropriately sets up and facilitates a shared decision-making conversation (first elicits preferences on who should be involved in decision making, then guides a shared exploration of the patient’s values and options for treatment). Similarly, we adapted existing learner-centered principles8 to assess five attributes of team leaders: fosters a stimulating learning climate (environment encourages questions and prioritizes learning), discusses learner goals (explicitly states goals and incorporates learner goals into teaching), presents material to enhance understanding (material clear and organized, emphasizing key points), provides constructive feedback (respectful exchange with concrete steps for improvement; includes positive and negative feedback), and promotes teamwork. After attending rounds, each rater independently scored the team leader’s 10 patient- and learner-centered attributes on five-point Likert scales and then came to a consensus score for each item.
For each team, raters recorded team demographics (number of members by type; leader type) and caseload characteristics (number of patients, duration of rounds).
We describe team demographic and caseload characteristics by service via median (interquartile range) frequencies and percentages. We summarize team leaders’ learner- and patient-centered care via composite means (SD) across the respective five attributes.
Topic-specific SBS outcomes.
For each SBS topic, patient-level topic prevalence is the proportion of patients for whom discussion of a topic was raised according to either rater, and topic positive-response rate is the proportion of discussions noted as “positive” by either rater, among patients for whom a topic was raised. We estimated mean (95% CI) frequencies of these dichotomous outcomes and tested for variation among services using generalized estimating equation (GEE) models with team as a random effect.
Across-topic SBS outcomes.
SBS topic count is the sum of all topics discussed per patient (range, 0 to 30). SBS positive-response rate was calculated as the percentage of topics discussed (per patient) that received positive scores: 100% × response count/topic count (where response count is the sum of topic discussions receiving positive scores). Thus, topic prevalence and topic positive-response rate distinguish among topics, whereas SBS topic count and SBS positive-response rate average over topics within a patient. We analyzed SBS topic count and SBS positive-response rate using GEE models as above assuming Poisson and binomially distributed outcomes, respectively. In bivariate models, we evaluated dependence of each (patient-level) outcome on (team-level) demographic, caseload, and patient- and learner-centered characteristics; for continuous variables, we included quadratic terms when statistically significant (α = .05). We constructed multivariable models by including all covariates except service and reducing the model to the statistically significant subset, then including service and its interactions with remaining covariates, and reducing this model similarly.26 Outcome estimates were generated from the final model at covariate levels typical of the overall sample, which we plotted to illustrate main relationships. We report Dunnett-Hsu adjusted P values testing for differences between services. We conducted all statistical analyses using SAS software, version 9.2 (SAS Institute, Cary, North Carolina).
We observed 20 rounding teams at four practice settings (services): IM and Peds at two teaching hospitals, one each at Stanford and UCSF (Table 1). IM teams typically included five members (e.g., one attending, one resident, two interns or medical students, and one non-MD), and Peds teams included seven to eight members (e.g., one attending, one resident, four interns or medical students, and one to two non-MDs). At Hospital 2, 82.5% of rounds were led exclusively by an attending, compared with 12.5% at Hospital 1 where shared leadership was more common. At both hospitals, rounds covered 2 to 13 (median, 8) patient cases during 0.8 to 3.5 hours (median, 2.0). Teams with the highest mean caseload spent 12 minutes per patient compared with 20 minutes for those with the lowest caseload.
Overall, learner-centered item scores ranged from 2.7 to 3.6, yielding a composite mean (SD) of 3.15 (0.65) (Table 1). Patient-centered item scores ranged from 2.0 to 3.5, yielding a composite of 2.81 (0.59). Shared decision-making components in the patient-centered domain scored lowest in all services, whereas learner-centered scores varied among services.
Prevalence of SBS topics
Of 622 patients seen by 80 teams, 97% had at least one SBS topic arise. Topic prevalence varied across the 30 topics (Table 2), ranging from 1.1% to 62%, with a median of 13%. The most common topics (with prevalence above the third quartile; 25%) were nutrition/diet, referral (adherence), social supports, resources, pain, and patient education. The least common topics (with prevalence below the first quartile; 5.6%) were prevention/screening, smoking, unsafe sexual behavior, gender/sexual orientation, spirituality, and integrative medicine.
The prevalence of most topics differed significantly among services. Alcohol, drugs, smoking, and socioeconomic status were discussed primarily by IM services. Exercise, prevention/screening, social supports, language, pain, and patient education were most commonly discussed by Peds-2. Behavior-change counseling topics were discussed primarily at Hospital 2.
The overall mean SBS topic count was 5.3 per patient (95% CI, 5.0–5.7), of 30 possible topics (third quartile = 7; maximum = 18). By service, the mean SBS topic count ranged from 3.7 (3.2–4.3) for Peds-1 to nearly double, 7.3 (6.9–7.8) for Peds-2 (P < .001; df = 3). Bivariable models indicate that SBS topic count was higher if team size was moderate rather than small or large. SBS topic count increased with lower patient census and more time per patient, and with short or long rounds rather than medium-length rounds. SBS topic count also increased with both patient- and learner-centeredness (Table 3).
Multivariable modeling of SBS topic count identified four significantly associated covariates. Evaluated at an “average” team’s characteristics (i.e., six members, composite patient-centeredness = 2.8, and eight patient encounters in two hours), the adjusted mean was 5.6 (95% CI, 5.3–6.0) topics per patient. The association of SBS topic count with team size varied by service (interaction P= .05, df = 3), rising with team size (1.05- to 1.1-fold higher per additional member) in three services but falling in the fourth service (Figure 2). For all services, mean SBS topic count also increased with greater patient-centeredness (1.18-fold higher per point; P < .001) and longer duration of rounds (1.08-fold higher per half-hour; P < .001) and decreased with higher patient census (0.96-fold as high per additional patient; P = .003). Changing the values of the covariates defining the “average” team would shift the rates upward or downward but would not change the slopes (Figure 2). After adjustment, differences between services, versus IM-1, were not statistically significant (Dunnett-Hsu P > .28). In particular, for Peds-1, which had the highest patient census and shortest duration of rounds and lowest patient-centered score (Table 1), adjustment raised the mean SBS topic count to 5.1 (4.4–5.8) for an “average” team; for Peds-2, with the lowest patient census, adjustment lowered the mean SBS topic count to 6.1 (5.6–6.7). Adjusted means for IM-1 and IM-2 were 5.2 (4.8–5.8) and 6.2 (5.5–7.1), respectively.
Responses to SBS topics
Topic positive-response rates ranged from 13% to 64%, with a median of 38% (Table 4) indicating the percentage of positive team responses by topic. Topic positive-response rates above the third quartile (47%) occurred for prevention/screening, literacy, spirituality, psychiatric illness, patient education, goal setting, and shared problem solving; rates below the first quartile (29%) occurred for referral (adherence), tests/procedures (adherence), alcohol, smoking, unsafe sexual behavior, social supports, and socioeconomic status. Some topic positive-response rates varied significantly among services: pain (higher at Hospital 1), social supports (higher in IM services). Likewise, there was variance in two aspects of medical adherence (both lowest in Peds-1): referrals and tests/procedures.
The mean SBS positive-response rate was 38% per patient (95% CI, 34–42; third quartile = 50; maximum = 100), indicating the percentage of positive team responses per patient across all SBS topics. In bivariable models, the SBS positive-response rate was not significantly associated with covariates studied, including service (P = .54; df = 3); however, it tended to increase with lower patient census, more time per patient, and patient-centeredness (Table 3). In multivariable models, no adjusted association was statistically significant (not shown).
Our main findings show that SBS topics arise frequently with nearly every patient encounter, and, for all services, the number of SBS topics raised is strongly associated with teams’ patient-centeredness. Further, team size influences how many topics are addressed: More team members were a distraction when minutes per patient were few but were an asset when more time was available. Traditionally stigmatized topics, such as alcohol and psychiatric illness, were raised less commonly than anticipated according to population prevalences.27,28 Although SBS topics were commonly discussed, team responses to these topics were positive in only 38% of opportunities, on average, suggesting that many SBS “teachable moments” are not being fully used. This tended to improve with lower caseloads and higher patient-centeredness ratings. Lastly, our findings show that there were opportunities for improvement in overall patient- and learner-centered behaviors during attending rounds.
Although team size, patient census, and pressures for rapid discharge are often described as barriers to quality inpatient clinical care and teaching,6,22,29 we found limited supporting evidence. Our analysis suggests that certain features of attending rounds can be positively associated with SBS topic prevalence. For instance, having sufficient time per patient, a service-appropriate team size, and giving careful attention to more patient-centered interactions were all associated with better attention to SBS topics. This is consistent with Balmer and colleagues’29 study, which found that contextual factors challenge, but do not prevent, bedside teaching.
Although case mix affects SBS topic relevance and varies between services (e.g., some topics are relevant for adults but not children), SBS topic discussion frequencies may also reflect clinicians’ acuity and self-efficacy in identifying and responding to patients’ circumstances. Clinicians may not understand how to make use of the seldom-raised topics in furthering patient care, whereas the often-raised topics may be easier to address. The wide variation in topic-specific prevalence should stimulate educators to teach how SBS information can be used to promote healing and prevent relapse.
Study implications are relevant to improvements in SBS teaching in clinical education. The observational tool provides a structured and quantitative means of capturing core competencies in both clinical teaching and inpatient clinical care, along with SBS topics. Our study shows that higher patient-centeredness is associated with significantly more SBS content raised during attending rounds. While alternative tools to assess clinical performance during rounds do exist to inform teaching opportunities,30,31 neither evaluates patient-centeredness nor quality of teaching. Direct observation paired with an assessment tool may be useful to evaluate and guide future clinical teaching efforts. This would require institutional buy-in, brief training surrounding use of the tool, and dedication of time to this endeavor. Currently, the Accreditation Council for Graduate Medical Education’s Next Accreditation System emphasizes the use of improved evaluations and observations of the clinical learning environment incorporating SBS topics such as patient safety, quality, health care disparities, transitions in care, and professionalism.32
A number of limitations pertain to our study. First, we only observed teams during attending rounds, which is a highly concentrated part of patient care and teaching but not the only opportunity. By potentially missing SBS topic discussions later in the day, our data may underestimate SBS topic count and topic prevalence. Second, we only recorded explicit, observable behavior and are unable to explain why topics were or were not raised; we did not factor in clinicians’ rationales, priorities, or patient case mix. For example, topics may have been intentionally excluded on the basis of leaders’ prior knowledge of team or patient needs. Consequently, we cannot provide a normative or prescriptive recommendation for the “correct” number of SBS topics that should be raised. Future studies might pair observations with postround interviews with leaders and learners to explore rationales for behaviors. Although our multisite study included a private and public hospital and two medical services (IM and Peds), it is unclear if our findings are generalizable to other settings beyond the two institutions or the two specialties. Furthermore, our observational methodology is limited and may have introduced unintended bias. Although rounding teams were unaware of what behaviors were being observed, being observed in general may cause alterations in behavior to be more socially desirable. Our findings, however, suggest they did not. We used the same behavioral anchors for attending and resident leaders, potentially creating unfair expectations for resident-led teams—more likely in Hospital 1 where more residents served as leaders. Although two independent trained raters came to consensus on learner- and patient-centered scores, initial interrater agreement was not calculated, and interpersonal dynamics may affect the process of arriving at a consensus score. Finally, our observational tool was developed for research purposes to evaluate provider-level engagement with SBS topics, and it did not include patient behaviors, perceptions of clinical care, or patient outcomes. Although the codesheet could be adapted for the purposes of direct clinical observation and feedback, it was not developed with this intent.
Findings from this observational study suggest that within the constraints of busy inpatient services, teams can be patient- and learner-centered and can find time to address SBS topics. Our findings also highlight opportunities for improvement. While historically primary and ambulatory care have provided the primary pulpit for the promotion of an SBS focus, we have identified clear needs and deficiencies in the inpatient clinical setting. Initial reparative steps should include awareness raising to address missed opportunities to both teach and address SBS in the context of patient care, and educational campaigns to highlight the impact of the “soft” SBS topics on “hard” clinical outcomes. Beyond recognizing the crucial role that social and behavioral factors play in health and disease, inpatient clinician educators require appropriate training in areas such as cultural sensitivity, motivational interviewing, and behavior change counseling to optimally respond to SBS topics as they arise. Optimal teaching strategies and methods to shift inpatient teaching cultures should be developed, tested, and further refined. Moreover, future studies should assess patient- and learner-centered outcomes associated with skillful use of SBS concepts.
Acknowledgments: The team is grateful for the dedication of the observers: Sarah Carillo, PharmD (UCSF), Charlie DeVries, MPH (UCSF), Narges Karimi, BS (California State University, East Bay), Annie Le, BA (UCSF), and Emily Weibel, BS (San Francisco State University). All observers were financially compensated for their time using grant funds. The authors are also thankful for the enthusiastic support of this project by the attendings and teams they observed and for the administrative support of Patrick Yuan, BA (UCSF).
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