title: "Learning by doing"--resident perspectives on developing competency in high-quality discharge care.
abstract: BACKGROUND
  Reducing readmissions and post-discharge adverse events by improving the quality of discharge care has become a national priority, yet we have limited understanding about how physicians learn to provide high-quality discharge care.
  
  
  METHODS
  We conducted in-depth, in-person interviews with housestaff physicians with qualitative analysis by a multi-disciplinary team using the constant comparative method to explore learning about high-quality discharge care as a systems-based practice and to identify opportunities to improve training around these concepts.
  
  
  RESULTS
  We analyzed interview transcripts from 29 internal medicine residents: 17 (59 %) were interns (PGY-2 or PGY-3), 12 (41 %) seniors, and 17 (59 %) were female. We identified a recurrent theme of lack of formal training about the discharge process, substantial peer-to-peer instruction, and "learning by doing" on the wards. Within this theme, we identified five specific concepts related to systems-based practice and high-quality discharge care which residents learned during residency: (1) teamwork and the interdisciplinary nature of discharge planning; (2) advanced planning strategies to anticipate challenges in the discharge process; (3) patient safety and the concept of a "safe discharge;" (4) patient continuity of care and learning from post-discharge outcomes and; (5) documentation of discharge plans as a valuable skill.
  
  
  CONCLUSIONS
  Discharge care is an overlooked opportunity to teach concepts of systems-based practice explicitly as learning about discharge care is unstructured and individual experiences may vary considerably. Educational interventions to standardize learning about discharge care may improve the development of systems-based practice during residency and help improve the overall quality of discharge care at teaching hospitals.
authors.affiliation: Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA 94113, USA. Ryan.Greysen@ucsf.edu
authors.forename: S Ryan
authors.initials: SR
authors.lastname: Greysen
authors.forename: Danise
authors.initials: D
authors.lastname: Schiliro
authors.forename: Leslie
authors.initials: L
authors.lastname: Curry
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
authors.forename: Leora I
authors.initials: LI
authors.lastname: Horwitz
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002983:Clinical Competence / Q000592:standards*; D003266:Continuity of Patient Care / Q000592:standards / Q000639:trends; D005260:Female; D006801:Humans; D007396:Internship and Residency / Q000592:standards* / Q000639:trends; D007858:Learning; D008297:Male; D010351:Patient Discharge / Q000592:standards* / Q000639:trends