Career Plans of Internal Medicine Residents From 2019 to 2021

This survey study examines career choices of internal medicine residents from 2019 to 2021 and compares them with findings from a decade earlier.

Visual thinking strategies for interprofessional education and promoting collaborative competencies

BACKGROUND

Interprofessional education (IPE) curricula require approaches that address the needs of learners from multiple professions and levels of clinical experience. Frameworks based in the arts and humanities, which can improve learners' skills in collaborative competencies such as communication and team building, remain limited in IPE. We describe the development, implementation and evaluation of a visual arts-based IPE session for over 400 interprofessional learners.

APPROACH

During the 90-min session held in 2021, an art museum educator first guided learners through observations of art works using the Visual Thinking Strategies (VTS) approach. Subsequently, small groups of six to eight interprofessional learners and two trained facilitators explored how their observations were influenced by personal and professional identities and made connections to interprofessional collaborative practice.

EVALUATION

Two hundred eleven of the 407 student attendees responded to the post-session survey (52%). Eighty percent of the respondents agreed or strongly agreed that 'the art of observation activity is an effective means of starting discussions with interprofessional teams.' On the Interprofessional Collaborative Competency Attainment Survey, a validated tool assessing changes in interprofessional collaboration-related competencies, there was a significant increase between pre- (M = 45.73, SD = 8.05, p < 0.001) and post-session scores (M = 51.46, SD = 7.97, p < 0.001), using a paired t-test analysis. Qualitative analysis of learners' takeaways identified themes of open-mindedness, hearing other opinions and perspectives, collaboration/teamwork, patient-centeredness and awareness of biases.

IMPLICATIONS

Our curricular approach shows how integrating visual arts-based pedagogies into IPE activities with learners from diverse disciplines and clinical experiences is both feasible and helpful for developing collaborative competencies.

A Case for Case Reports: How to Write One and Promote Mentorship, Scholarship and Faculty Development

Introduction Case reports form the base layer of the evidence pyramid, describing new or emerging diseases, side effects to treatments, common presentations of rare diseases, or rare presentations of common diseases. An important scholarly pursuit, writing case reports can be hindered by lack of time, training, and mentorship. Here, we describe a workshop incorporating case writing skills with mentorship opportunities to engage faculty and learners. Methods We designed and implemented a virtual, synchronous workshop addressing knowledge and attitudes on case reports for trainees and academic faculty at distributed sites. Participants discussed the contributions of case reports to the medical literature, key features of successful cases, approaches to writing learning objectives, and how to develop interesting cases into dynamic case reports. Case reports were discussed as a way to mentor learners to disseminate interesting cases as a source of clinical experience and academic productivity. A retrospective pre-post survey was collected two months after the workshop to evaluate its utility. Results Fifteen out of 42 participants responded to the survey. As a result of the workshop, respondents noted improvement in confidence in identifying and writing case reports and identifying and working with mentors or mentees, regardless of level of training or specialty. At the follow-up, seven (47%) respondents had identified a case and 10 (67%) had identified a mentor/mentee to write a case report with. Discussion This workshop, successfully delivered virtually, demonstrates the utility of a brief educational intervention in improving participant confidence in identifying and writing case reports with mentorship.

Reversible dementia in the setting of multiple medical comorbidities due to B12 deficiency

Vitamin B12 deficiency is a cause of reversible dementia that must be ruled out in the evaluation of neurocognitive decline. We present a case of neurocognitive decline secondary to B12 deficiency where the workup was obscured by multiple competing diagnoses and treatment with empiric B12 supplementation reversed symptoms. Although the pretest probability was low, the morbidity from undiagnosed B12 deficiency is high, warranting a trial of B12 supplementation that resolved the patient's symptoms.

Expanding Knowledge and Changing Attitudes About Poverty: An Interactive, Interprofessional Approach

BACKGROUND

Poverty negatively affects the lives and health of the poor. However, health professionals often have limited personal experience and receive little formal education on surviving under conditions of poverty in the United States, which may contribute to suboptimal patient care and outcomes.

PURPOSE

We conducted a 3-h, interactive, experiential poverty simulation workshop with an interprofessional group of pre-professional health students to increase their comprehension about the realities of poverty.

METHOD

As part of the evaluation, participants completed a self-assessment of their attitudes and skills using a Likert scale and open-ended questions; a reflection prompt about how the workshop might affect their professional practice; and a pre- and post-assessment questionnaire.

DISCUSSION

Participants' attitudes about low-income patients became more favorable; they gained awareness and expressed empathy through the role-play experience. Our analysis revealed increased understanding of social determinants of health, of life challenges that patients face outside of healthcare, and that solutions must be collaborative as the challenges facing poor patients are multifactorial.

CONCLUSION

The workshop allowed interprofessional students to learn from and with each other about the experiences of poor patients. Future sessions should emphasize interprofessional skill-building and action, potentially in virtual formats.

Developing a team-based assessment strategy: direct observation of interprofessional team performance in an ambulatory teaching practice

Background: High functioning interprofessional teams may benefit from understanding how well (or not so well) a team is functioning and how teamwork can be improved. A team-based assessment can provide team insight into performance and areas for improvement. Though individual assessment via direct observation is common, few residency programs in the United States have implemented strategies for interprofessional team (IPT) assessments. Methods: We piloted a program evaluation via direct observation for a team-based assessment of an IPT within one Internal Medicine residency program. Our teams included learners from medicine, pharmacy, physician assistant and psychology graduate programs. To assess team performance in a systematic manner, we used a Modified McMaster-Ottawa tool to observe three types of IPT encounters: huddles, patient interactions and precepting discussions with faculty. The tool allowed us to capture team behaviors across various competencies: roles/responsibilities, communication with patient/family, and conflict resolution. We adapted the tool to include qualitative data for field notes by trained observers that added context to our ratings. Results: We observed 222 encounters over four months. Our results support that the team performed well in measures that have been iteratively and intentionally enhanced – role clarification and conflict resolution. However, we observed a lack of consistent incorporation of patient-family preferences into IPT discussions. Our qualitative results show that team collaboration is fostered when we look for opportunities to engage interprofessional learners. Conclusions: Our observations clarify the behaviors and processes that other IPTs can apply to improve collaboration and education. As a pilot, this study helps to inform training programs of the need to develop measures for, not just individual assessment, but also IPT assessment.

Impact of the New York State Prescription Drug Monitoring Program (IStop) on chronic pain management by primary care providers

OBJECTIVE

To explore the impact of the New York State Prescription Drug Monitoring Program (IStop) on the self-reported management of patients with chronic pain by primary care providers.

DESIGN

Mixed-methods study with survey collection and semistructured interviews.

SETTING

Multiple academic hospitals in New York.

PARTICIPANTS

One hundred and thirty-six primary care providers (residents, fellows, attendings, and nurse practitioners) for survey collection, and eight primary care clinicians (residents, attending, and pharmacist) for interviews.

INTERVENTIONS

Introduction of IStop.

MAIN OUTCOME MEASURE(S)

Change in usage of four risk reduction strategies (pain contracts, urine tests, monthly visits, and comanagement) as reported by primary care providers for patients with chronic pain.

RESULTS

After the introduction of IStop, 25 percent (32/128) of providers increased usage of monthly visits, 28 percent (36/128) of providers increased usage of pain management comanagement with other healthcare providers, and 46 percent (60/129) of providers increased usage of at least one of four risk reduction strategies. Residents indicated much higher rates of change in risk reduction strategies due to IStop usage; increasing in the use of monthly visits (32 vs. 13 percent, p = 0.02) and comanagement (36 vs. 13 percent, p = 0.01) occurred at a much higher rate in residents than attending physicians. Interview themes revealed an emphasis on finding opioid alternatives when possible, the need for frequent patient visits in effective pain management, and the importance of communication between the patient and provider to protect the relationship in chronic pain management.

CONCLUSIONS

After the introduction of IStop, primary care providers have increased usage of risk reduction strategies in the care of chronic pain patients.

The Financial Cost of Interprofessional Ambulatory Training: What's the Bottom Line?

BACKGROUND

Team-based care is recommended as a building block of high-performing primary care but has not been widely adapted in training sites. Cost may be one barrier to a team-based approach.

OBJECTIVE

We quantified incremental annual faculty and staff costs as well as potential cost savings associated with an interprofessional (IP) ambulatory training program compared to a traditional residency clinic at the same site.

METHODS

Cost calculations for the 2017-2018 academic year were made using US Department of Labor median salaries by profession and divided by the number of residents trained per year. Cost implications of lower no-show rates were calculated by multiplying the difference in no-show rate by the number of scheduled appointments, and then by the weighted average of the reimbursement rate.

RESULTS

A total of 1572 arrived appointments were seen by the 10 residents in the IP program compared with 8689 arrived appointments seen by 57 residents in the traditional clinic. The no-show rate was 11.5% (265 of 2311) in the IP program and 19.2% (2532 of 13 154) in the traditional clinic (P < .001). Total cost to the health system through higher staffing needs was $113,897, or $11,390 per trained resident.

CONCLUSIONS

Total costs of the IP model due to higher faculty and staff to resident ratios totaled $11,390 per resident per year. Understanding the faculty and staff costs and potential cost-saving opportunities associated with transformation to an IP model may assist in sustainability.

The serving temperature effect: Food temperature, expected satiety, and complementary food purchases

We show that the temperature at which foods and beverages are served impacts consumers' complementary purchases, defined as additional foods and beverages purchased for a consumption episode. Across a series of studies, including field studies and controlled laboratory experiments, we show that consumers choose more complementary food items when they consume or intend to consume a food or beverage served cold rather than hot. This occurs because cold consumables are expected to be less satiating compared to hot consumables. Serving temperatures that increase complementary purchasing may enhance the firm's bottom line, but could add unnecessary calories to the meal, and thus is of interest to both consumers and managers.

Access and Continuity: A Multidisciplinary Education Workshop to Teach Patient-Centered Medical Home (PCMH) Principles

INTRODUCTION

As more practices move to patient-centered medical home (PCMH) models, future health care professionals must train to work in collaborative settings. We implemented a 3-hour workshop for multidisciplinary trainees on the PCMH principles of access and continuity based on the EFECT framework (eliciting a patient-centered narrative, facilitating an interprofessional team discussion, evaluating the clinical evidence, creating a shared care plan, and tracking outcomes).

METHODS

Participants included internal medicine residents and medical, physician assistant (PA), and clinical psychology students. The workshop incorporated reflective activities identifying patient and provider health care delivery priorities, plus a PCMH presentation and group activities focusing on access and continuity. Evaluations were analyzed qualitatively and quantitatively.

RESULTS

The workshop had 39 participants (seven physicians, one PA, one educator, one psychologist, three staff, nine residents, one PA student, one psychology extern, and 15 medical students). On a 0-10 Likert scale (0 = don't agree at all, 10 = completely agree), learners reported higher knowledge of PCMH principles (M = 8.8), feeling better prepared for PCMH work (M = 8.6), and having obtained real-world skills (M = 8.3). Open-ended responses describing the workshop's take-home message included the role of patient-centeredness in clinical redesign, the value of the multidisciplinary team in optimizing access and continuity, and how to use a quality improvement approach for access and continuity.

DISCUSSION

This workshop increased PCMH-related knowledge and encouraged discussion of professional roles within the team. Learners recognized the benefits of team-based rather than provider-centric approaches to access and continuity.

"A PCMH mind and a PCMH heart": Patient, faculty, and learner perspectives on collaborative care in an interprofessional team-based training programme

RATIONALE, AIMS, AND OBJECTIVES

Providing high-quality primary care in patient-centred medical homes (PCMHa) requires competencies that can only be provided by interprofessional (IP) education. The benefits of collaborative training have been documented for learners, but less is known about the perceptions of the clinical professionals who train the learners or the patients receiving IP primary care. This investigation compared stakeholder attitudes about IP education, training, and providing collaborative care prior to developing a new IP training programme.

METHODS

We conducted five focus groups at a large general internal medicine training practice. Learner and faculty groups included participants from medicine, psychology, pharmacy, and physician assistant professions; three patient groups were held to obtain perspectives on receiving health care from IP trainees. We used inductive analysis to identify themes across the three stakeholder groups.

RESULTS

We identified seven convergent themes across all three stakeholder groups: (a) team engagement, (b) technology in care delivery, (c) cost of care, (d) involving patients in learning, (e) time constraints, (f) scope of practice, and (g) autonomy/interdependence. Each group emphasized the need to define and communicate team members' roles. Learners anticipated high-quality IP interactions, and patients noted the benefits of receiving care from well-supervised trainees. Faculty struggled to navigate the training needs of diverse learner groups and to integrate PCMH mandates focused on documentation with authentic patient-centred care.

CONCLUSIONS

This is the first reported data comparing perceptions about IP training and care across these three stakeholder groups. Results suggest the need to clarify scope of practice, define professional roles, and bridge gaps between teaching PCMH principles and subsequently providing high-quality health care. Results inform faculty development needs in learning ways to train learners across professions and outline ways to structure interactions with patients.

Contract Negotiation Skills: A Workshop for Women in Medicine

INTRODUCTION

Contract negotiation is a high-stakes interaction, yet most physicians are never taught negotiation skills. Studies suggest that women, as compared with men, display a lower propensity to initiate negotiations and negotiate less competitively, highlighting a need for training to help level the playing field for female physicians.

METHODS

We devised a learner-centered workshop for female physicians that included a mini-didactic on negotiation principles, a question-and-answer time with a lawyer, an interactive role-play on contract negotiation style, and guided reflection. The workshop was intended for women in medicine from the level of medical student to full professor. The workshop was evaluated by pre- and postworkshop surveys with quantitative questions assessing perceived comfort with and knowledge of negotiation skills and strategies, as well as qualitative questions assessing lessons learned and areas for improvement.

RESULTS

After the workshop, participants (n = 34) reported significantly improved comfort with contract negotiation (p < .01) and with negotiation skills and strategies (p < .01). Through qualitative evaluation, we discovered that participants gained an appreciation for the self-advocacy in negotiation, as well as a better understanding of negotiation logistics. We also received positive feedback from participant comments, with most learners reporting that the topic was useful and worthwhile.

DISCUSSION

We believe that this workshop fills a gap in the literature regarding contract negotiation training for physicians while also helping to level the playing field with regard to female physicians and the gender pay gap.

A novel longitudinal interprofessional ambulatory training practice: the improving patient access care and cost through training (IMPACcT) clinic

Few graduating health professionals choose primary care. Trainees satisfied with continuity ambulatory experiences are more likely to pursue primary care. The authors developed a longitudinal interprofessional ambulatory training program to improve team-based care and encourage primary care careers. The Improving Patient Access Care and cost through Training (IMPACcT) clinic, launched in 2016, includes physician, physician assistant, pharmacy, and psychology trainees. Residents, faculty, and interprofessional trainees complete "on-service" weeks together. Co-located administrative team members coordinate care and lead team "huddles." Interprofessional signout facilitates patient follow-up. The initial evaluation included process and quality indicators compared to the traditional resident practice. Learners reported increased perceived competence in interprofessional communication and teamwork after completing their training. Clinical quality outcomes suggested improved provider continuity and arrival rate compared to traditional resident practice (56.5% vs. 32.9%; 66.3% vs. 62.2%, p < .01). Patient satisfaction was higher in the IMPACcT clinic in the areas of coordinated care and team functioning. Ten of eighteen physician graduates in the program chose further training in primary care compared to 20 of 150 graduates not in the program (55.6% vs. 13.3%, p < .01). Implementing a longitudinal team-based ambulatory interprofessional training practice was associated with improved continuity of care and improved patient satisfaction indicators.

Design thinking in medical ethics education

BACKGROUND

Design thinking (DT) is a tool for generating and exploring ideas from multiple stakeholders. We used DT principles to introduce students to the ethical implications of organ transplantation. Students applied DT principles to propose solutions to maximise social justice in liver transplant allocation.

METHODS

A 150 min interactive workshop was integrated into the longitudinal ethics curriculum. Following a group didactic on challenges of organ donation in the USA supplemented by patient stories, teams of students considered alternative solutions to optimise fairness of organ distribution and ethical implications of changing the current model. Facilitators led students through DT steps of empathy, defining the team's point of view, ideating on potential solutions, prototyping a specific idea and testing the idea through oral presentation, with questions and answers by peers and faculty. The curriculum was evaluated with presurveys and postsurveys including quantitative and open-ended items.

RESULTS

100 first year medical students participated. Before the session, 75.3% of students had no practical experience with DT. Following participation, students reported an increased understanding of the current liver transplant allocation system (p<0.01) and an increased appreciation of shortcomings of the current organ allocation system (p<0.01). After the session, 73.8% of students felt that DT could be used to approach complex health system problems.

DISCUSSION

Students participating in a DT workshop displayed improved knowledge and attitudes toward organ transplantation and DT. In this pilot study, DT showed promise as a student-led approach emphasising collaboration and creativity in ethics curricula in medical education.

An interprofessional experience in diabetes management for pharmacy and medical students

BACKGROUND AND PURPOSE

The 2016 Standards of the Accreditation Council for Pharmacy Education state that curricula must include opportunities for interprofessional education (IPE). This report describes a collaborative effort between a pharmacy program and a school of medicine to develop, implement, and evaluate an interprofessional workshop focused on collaborative disease management.

EDUCATIONAL ACTIVITY AND SETTING

A medical school course in diabetes management was identified as optimal for an IPE approach. One class session was designed to highlight the advantages of team-based care in diabetes management and describe the roles of members of an interprofessional healthcare team. Students were divided into groups to discuss cases and demonstrate diabetic device counseling. Students were surveyed before and after the IPE experience to examine their attitudes towards interprofessional learning.

FINDINGS

We obtained matched pre and post-evaluations from 168 participants (138 medical students and 30 pharmacy students). Learner attitudes were positive overall, and improved from pre-test (M = 80.28, SD = 10.29) to post-test (M = 82.83, SD = 9.40, F = 14.92, df = 1, p < .001), suggesting more favorable attitudes to interprofessional learning after completing the class. Multivariate analysis indicated a significant main effect for learner profession, suggesting pharmacy students had more positive attitudes to interprofessinal learning both before and after the workshop.

SUMMARY

Adding an IPE dimension to an existing medical school course had a positive impact on student perceptions of interprofessional practice, particularly for the pharmacy students who could demonstrate the value of their role on a team for patient care.

Implementation of an Interprofessional Nutrition Workshop to Integrate Nutrition Education into a Preclinical Medical School Curriculum

Objective: The patient-physician encounter provides an ideal opportunity to assess a patient's dietary history and its impact on total health. However, nutrition assessments and counseling in physician-patient encounters is often lacking. Insufficient nutrition education during medical school may lead to insecurity in assessing and counseling patients.Methods: Physicians and registered dietitians (RD) co-developed and co-facilitated a nutrition workshop for first-year medical students. Goals included increasing recognition of nutrition's impact on health and promoting student confidence and skills when attaining a nutrition history, assessing risk factors, and advising.Results: Seventy percent of students attested to having "sufficient" knowledge to counsel a patient on nutrition after the session compared to 38% before (Z= -4.46, p < 0.001). Sixty eight percent felt comfortable completing a nutritional assessment after the session compared to 35% before (Z= -4.30, p < 0.001). Sixty-three percent felt confident in advising patients about nutrition after the session compared to 32% before (Z= -4.20, p < 0.001). Students also significantly outperformed a control cohort on a nutrition-related component of an Objective Standardized Clinical Examination.Conclusions: Clinical nutrition education can be successfully integrated into the medical school curriculum as early as the first year. Interprofessional collaboration with RDs provided evidence-based content and authentic clinical experience in both the development of the workshop and in facilitating student discussion.

Perceptions of a longitudinal standardized patient experience by standardized patients, medical students, and faculty

BACKGROUND

Longitudinal standardized patient (LSP) experiences mimic clinical practice by allowing students to interact with standardized patients (SPs) over time. LSP cases facilitate practice, assessment, and feedback in clinical skills and foster an appreciation for the continuum of care.

OBJECTIVE

We sought to characterize the nature of relationship-building, feedback, and continuity among all stakeholders participating in a single LSP program.

DESIGN

We developed and implemented a novel LSP program. Students encountered two LSP characters six times each during the first 2 years of medical school, though continuity pairings of students, SPs, and faculty were frequently not possible. Focus groups were held with second-year medical students (N = 15), core faculty who coached these students in LSP encounters (N = 8), and SPs who had played the role of either LSP character (N = 10) participated. Results were analyzed thematically using a template analysis approach.

RESULTS

The longitudinal nature of the experience reinforced the importance of student growth over time, the key role of faculty and SPs in providing feedback, and the tension between feedback and assessment. Students reported that LSP cases encouraged practice and feedback. SPs felt wedded to the longitudinal characters. Continuity pairings were recommended by all stakeholders to increase authenticity and promote relationship-building.

CONCLUSION

Stakeholders observed that the LSP cases brought some sense of continuity missing in other clinical skills encounters which helped prepare students for patient care. Continuity pairings of students, faculty, and SPs were recommended to enhance relationship-building and feedback.

There's a Lot More to Being a Physician: Insights From an Intensive Clinical Shadowing Experience in Internal Medicine

Phenomenon: Although most premedical students shadow physicians prior to starting medical school, there is no set of guidelines or expectations to facilitate effective experiences for students and physicians, nor is there data on the value of shadowing medical trainees as a way to learn about the training environment. We sought to understand premedical student perspectives on an intensive resident shadowing experience.

APPROACH

This was a qualitative study using anonymous data from focus groups conducted with premedical student participants in a month-long time motion analysis of internal medicine interns at two large academic medical centers. The authors convened, professionally transcribed verbatim, and analyzed data using step-by-step thematic analysis from 3 focus groups in 2012. Focus group questions included goals of participants, shadowing experiences, patient safety experiences, and thoughts on physician training.

FINDINGS

Twenty of the 22 students who were involved in the time motion study participated in the focus groups (91%). Three major themes were generated from the transcripts: qualities of a good physician, the inefficiencies of the healthcare system and the hospital, and the realities of graduate medical education. Insights: The intensive shadowing experience exposed premedical students to the hospital environment and many of the challenges they will face as future residents. Observing patient care firsthand, students considered the qualities of good intern physicians and appreciated the teamwork and collaboration essential to patient care in an academic medical center. Students witnessed some of the fundamental challenges of graduate medical training, including time pressures, documentation requirements, and the medical hierarchy. They also observed the difficulties of providing quality care in the current healthcare system, including hospital inefficiencies, interprofessional tensions, and financial barriers to care. Intensive shadowing of residents can begin the process of socialization to the culture of medicine by giving premedical students a realistic perspective of both positive and negative aspects of medical training and inpatient care.

Health and wellness among incoming resident physicians: A multi-domain survey

Introduction

Burnout and depression are well-described in medical students and physicians and can lead to adverse personal and patient outcomes; however, their time course and risk factors remain understudied. Here, we measured multiple domains of mental and physical health and wellness and assessed gender differences among incoming physician trainees beginning residency at an academic medical center.

Methods

Using a cross-sectional study design, all incoming trainees (i.e. housestaff) at Johns Hopkins Hospital received a questionnaire assessing depression, burnout, sleep, exercise, and alcohol consumption, among other domains. Standardized instruments were utilized for questionnaire development. Tests of significance were two-tailed.

Results

196 of 229 incoming housestaff (86%) completed the survey, and 49% were female. A history of depression was reported in 8%, and 5.4% met criteria for at least moderate depression by Patient Health Questionnaire (PHQ-9). Females were more likely to report a history of depression than males (13% vs. 3%, p=0.02) but had similar PHQ-9 scores. Four percent of participants reported feeling they were in the wrong profession. Goal and mean sleep were 7 and 6.7 hours/night, respectively. Forty-seven percent reported exercising once/week or not at all. While mean reported weekly alcohol consumption was three drinks, participants reported consuming ≥5 drinks in one sitting on average 1.6 times in the prior 6 months, and 4% used alcohol to sleep.

Conclusions

Incoming housestaff reported generally favorable mental and physical health at the beginning of residency training. However, exercise rates were low, and ill-suited alcohol consumption was noted, though infrequent. The few areas of possible improvement were largely similar between males and females. Wellness interventions might capitalize on the relatively high morale and health at the completion of medical school by helping to promote healthy habits, including regular exercise and avoidance of excess alcohol consumption, throughout future training and practice.

Perioperative COX-2 inhibitors may increase the risk of post-operative acute kidney injury

BACKGROUND

In enhanced recovery protocols (ERP), a restrictive fluid regimen is proposed. Patients who undergo major surgery have an increased risk of post-operative acute kidney injury (AKI). This combination may pose difficulties when ERP is used for patients undergoing major surgery. The aim of this study was to evaluate whether patients undergoing pancreatic surgery and treated with a restrictive fluid regimen are at greater risk of post-operative AKI. Furthermore, if there was an increased risk of AKI, we aimed to identify its cause.

METHODS

We reviewed the medical records of patients who underwent pancreatic surgery during 2014 (preERP, n = 58) and 2015 (ERP, n = 65). Fluid balance, the administration of cyclooxygenase-2 inhibitors, creatinine levels and mean arterial pressure were recorded. The Kidney Disease: Improving Global Outcomes criteria were used to define AKI.

RESULTS

The incidence of AKI was higher in the ERP group than in the PreERP group (12.5% vs. 1.8%, respectively, P = 0.035). The increased incidence of AKI could not be explained by differences in comorbidities, age, pre-operative creatinine or perioperative hypotension. Administration of coxibs was higher in the ERP group and was associated with increased incidence of post-operative AKI (P = 0.018). The combination of coxibs and restrictive fluid regimen seems particularly harmful.

CONCLUSION

Pancreatic surgery with a restrictive fluid regimen carries an increased risk of post-operative AKI if patients are also treated with cyclooxygenase-2 inhibitors. It is therefore suggested that in protocols including a restrictive fluid regimen for open pancreatic surgery, the use of cyclooxygenase-2 inhibitors should be avoided.

Do medical residents perform patient-centered medical home tasks? A mixed-methods study

BACKGROUND

Increasingly, residents are being trained in Patient-centered Medical Home (PCMH) settings. A set of PCMH entrustable professional activities (EPAs) for residents has been defined but not evaluated in practice.

OBJECTIVE

To understand whether residents trained at PCMH sites reported higher likelihood of engaging in PCMH tasks than those training in non-PCMH sites.

DESIGN

Survey and nominal group data from post-graduate trainees at three residency programs.

RESULTS

A total of 179 residents responded (80% response). Over half (52%) cared for patients at PCMH sites. Residents at PCMH sites were more likely to report engaging in tasks in the NCQA domains of enhancing access and continuity (p < 0.01 for 4/11 tasks), planning and managing care (p < 0.01 for 3/4 tasks), providing self-care and community support (p < 0.01 for 3/5 tasks), and identifying and managing patient populations (p < 0.01 for 1/6 tasks), but were not more likely to report tracking and coordinating care or measuring and improving performance. Residents at PCMH sites were more likely to report working with medical assistants (p < 0.01), but not other healthcare professionals. Qualitative data showed staff teamwork and continuity of care as facilitators of patient-centered care, and technological problems and office inefficiencies as barriers to care.

CONCLUSIONS

Residents trained at PCMH sites were more likely to engage in tasks in several NCQA domains, but not care coordination and quality assessment. Similar facilitators and barriers to trainee provision of patient-centered care were cited regardless of PCMH status. Curricula on PCMH principles and workflows that foster continuity and communication may help to inform residents on PCMH tenets and incorporate residents into team-based care.

ABBREVIATIONS

EPA: Entrustable professional activity; GIM: General Internal Medicine; NCQA: National Center for Quality Assurance; PCMH: Patient-centered medical home.

Barriers and Facilitators of Implementation of a Mandate for Influenza Vaccination among Healthcare Personnel

Mandatory influenza vaccination is associated with improved healthcare personnel vaccination rates, but institutional barriers to implementation and enforcement are reported. We explored barriers and facilitators to mandatory vaccination among a national sample of hospital administrators. Support from employees and administration were cited as key to the success of a mandate.

Infect Control Hosp Epidemiol 2014;35(6):724-727

Assessing intern handover processes

BACKGROUND

New standards for resident work hours set in 2011 changed the landscape of patient care in teaching hospitals, and resulted in new challenges for US residency training programmes to overcome. One such challenge was a dramatic increase in the number of patient handovers performed by residents. As a result, there is a renewed focus for clinical teachers to develop educational strategies to optimise the patient handover process and improve the quality of patient care and safety.

METHODS

In order to investigate current gaps in resident handovers, we examined the handover processes performed by medicine interns at two academic medical centres in Baltimore, Maryland, USA. We used trained observers to collect data on whether handovers were conducted face to face, with questions asked, in private locations, with written documentation, and without distractions or interruptions. Results were analysed using chi-square tests, and adjusted for clustering at the observer and intern levels.

RESULTS

Interns successfully conducted handovers face to face (99.5%), asked questions (85.3%), used private locations (91%), included written handover documentation (95.8%) and did not experience distractions for the majority of the time (87.7%); however, interruptions were pervasive, occurring 41.3 per cent of the time. In order to investigate current gaps in resident handovers, we examined the handover processes performed by medicine interns

DISCUSSION

Interns conducted patient handovers face to face, with questions asked, in private locations, with written documentation and without distractions the majority of the time; however, interruptions during the handover process were common. Exploring gaps at the individual programme level is a critical first step to develop effective teaching strategies to optimise handovers in residency.

Inpatient safety outcomes following the 2011 residency work-hour reform

BACKGROUND

The impact of the 2011 residency work-hour reforms on patient safety is not known.

OBJECTIVE

To evaluate the association between implementation of the 2011 reforms and patient safety outcomes at a large academic medical center.

DESIGN

Observational study using difference-in-differences estimation strategy to evaluate whether safety outcomes improved among patients discharged from resident and hospitalist (nonresident) services before (2008-2011) and after (2011-2012) residency work-hour changes.

PATIENTS

All adult patients discharged from general medicine services from July 2008 through June 2012.

MEASUREMENTS

Outcomes evaluated included length of stay, 30-day readmission, intensive care unit (ICU) admission, inpatient mortality, and presence of Maryland Hospital Acquired Conditions. Independent variables included time period (pre- vs postreform), resident versus hospitalist service, patient age at admission, race, gender, and case mix index.

RESULTS

Patients discharged from the resident services in the postreform period had higher likelihood of an ICU stay (5.7% vs 4.5%, difference 1.4%; 95% confidence interval [CI]: 0.5% to 2.2%), and lower likelihood of 30-day readmission (17.2% vs 20.1%, difference 2.8%; 95 % CI: 1.3 to 4.3%) than patients discharged from the resident services in the prereform period. Comparing pre- and postreform periods on the resident and hospitalist services, there were no significant differences in patient safety outcomes.

CONCLUSIONS

In the first year after implementation of the 2011 work-hour reforms relative to prior years, we found no change in patient safety outcomes in patients treated by residents compared with patients treated by hospitalists. Further study of the long-term impact of residency work-hour reforms is indicated to ensure improvement in patient safety.

I take therefore I choose? The impact of active vs. passive acquisition on food consumption

This research investigates the consequences of physically taking (actively acquiring) vs. receiving (passively acquiring) food items. Specifically, we demonstrate that the act of physically taking food can generate a false impression of choice, an effect we term "embodied illusion of choice." Across two studies, we document the mediating effect of this embodied illusion of choice on food evaluation and actual consumption, and show that these effects are moderated by an individual's need-for-control.

Identifying patient, community and program specific barriers to free specialty care utilization by uninsured patients in East Baltimore

Uninsured individuals face multiple barriers to accessing specialty care. The Access Partnership (TAP) offers free specialty care and care coordination to qualified uninsured patients at an urban academic medical center for a small program entry fee (waived for financial hardship). In the program's first year, 104 eligible patients (31%) did not enroll. To understand why, we investigated demographic, referral, personal, and program-specific factors. After adjusting for age, gender, and ZIP code, diagnostic and therapeutic referrals were more likely to be completed than ancillary referrals (OR=8.56, p=.001; OR 3.53, p=.03). There was no difference between pain related and ancillary referrals (OR=2.80, p=.139). Eighteen patients were surveyed and reported program and patient-specific barriers. While removing costs is necessary to improve access to specialty care for underserved patients, it is insufficient. Improving communication from program coordinators and enrollment strategies may help to improve utilization of free care programs by the uninsured.

We could have done a better job: a qualitative study of medical student reflections on safe hospital discharge

Because safe transitions of care are critical to patient safety, it is important to prepare physician trainees to assist in patient transitions from the hospital. As part of a discharge skills workshop for medical students, a brief reflective exercise was used to understand student perceptions of discharge problems and encourage application of classroom learning. Written reflections completed before and after the workshop were analyzed qualitatively to identify barriers to discharge observed on clinical clerkships and evaluate how the discharge skills workshop influenced student understanding of safe discharges. Students also completed a quantitative evaluation of the workshop. Seventy-eight of the 96 students (81%) at the Johns Hopkins University School of Medicine who participated in the discharge skills workshop volunteered to submit their written reflections. Eighteen themes were identified within two domains (barriers to safe discharges and solutions to improve discharges). The most commonly cited barrier was the sense that the discharge was rushed or premature. Three of the barrier themes and six of the solution themes were related to the importance of communication and collaboration in safe discharges. Students reported that the reflective exercise personalized the learning experience (mean 3.27 ± 0.86 on a scale of 1 (not at all) to 4 (a lot)). Students observed barriers to safe discharges on their clerkships related to poor communication, insufficient time spent planning discharges, and lack of patient education. Brief reflection encouraged students to apply lessons learned in a didactic session to consider solutions for providing safer patient care.

Coverage isn't enough: building primary care capacity in the setting of health reform

The Access Partnership is a program linking uninsured patients with primary and specialty care. Expansion of primary care access resulted in an influx of patients with multiple chronic conditions, causing the primary care practice to reach capacity after seven months. Our program may provide lessons in ensuring primary care access as the Affordable Care Act is implemented.

Variability in hand hygiene practices among internal medicine interns

Hand hygiene compliance remains suboptimal among physicians despite quality improvement efforts. We observed hand hygiene compliance among 29 medicine interns at 2 large academic institutions. Overall compliance was 75%. Although 4 interns averaged <40% compliance, 14 averaged at least 80%. Given variability observed among individuals in the same training programs, targeting those with poor performance may be important in improving overall compliance.

Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter

Etiquette-based communication may improve the inpatient experience but is not universally practiced. We sought to determine the extent to which internal medicine interns practice behaviors that characterize etiquette-based medicine. Trained observers evaluated the use of 5 key communication strategies by internal medicine interns during inpatient clinical encounters: introducing one's self, explaining one's role in the patient's care, touching the patient, asking open-ended questions, and sitting down with the patient. Participants at 1 site then completed a survey estimating how frequently they performed each of the observed behaviors. A convenience sample of 29 interns was observed on a total of 732 patient encounters. Overall, interns introduced themselves 40% of the time and explained their role 37% of the time. Interns touched patients on 65% of visits, asked open-ended questions on 75% of visits, and sat down with patients during 9% of visits. Interns at 1 site estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P < 0.01; 80% vs 37%, P < 0.01; and 58% vs 9%, P < 0.01, respectively). Resident physicians introduced themselves to patients, explained their role, and sat down with patients infrequently during observed inpatient encounters. Residents surveyed tended to overestimate their own practice of etiquette-based medicine.

Residency schedule, burnout and patient care among first-year residents

BACKGROUND

The 2011 US Accreditation Council for Graduate Medical Education (ACGME) mandates reaffirm the need to design residency schedules to augment patient safety and minimise resident fatigue.

OBJECTIVES

To evaluate which elements of the residency schedule were associated with resident burnout and fatigue and whether resident burnout and fatigue were associated with lower perceived quality of patient care.

METHODS

A cross-sectional survey of first-year medicine residents at three hospitals in May-June 2011 assessed residency schedule characteristics, including hours worked, adherence to 2003 work-hour regulations, burnout and fatigue, trainee-reported quality of care and medical errors.

RESULTS

Response rate was 55/76 (72%). Forty-two of the 55 respondents (76%) met criteria for burnout and 28/55 (51%) for fatigue. After adjustment for age, gender and residency programme, an overnight call was associated with higher burnout and fatigue scores. Adherence to the 80 h working week, number of days off and leaving on time were not associated with burnout or fatigue. Residents with high burnout scores were more likely to report making errors due to excessive workload and fewer reported that the quality of care provided was satisfactory.

CONCLUSIONS

Burnout and fatigue were prevalent among residents in this study and associated with undesirable personal and perceived patient-care outcomes. Being on a rotation with at least 24 h of overnight call was associated with higher burnout and fatigue scores, but adherence to the 2003 ACGME work-hour requirements, including the 80 h working week, leaving on time at the end of shifts and number of days off in the previous month, was not. Residency schedule redesign should include efforts to reduce characteristics that are associated with burnout and fatigue.

Does Access to Comprehensive Outpatient Care Alter Patterns of Emergency Department Utilization Among Uninsured Patients in East Baltimore?

Background: The annual number of emergency department (ED) visits in the United States increased 23% between 1997 and 2007. The uninsured and those with chronic medical conditions are high users of emergency care. Objective: We sought to determine whether access to comprehensive outpatient primary and specialty care and care coordination provided by The Access Partnership (TAP) reduced ED utilization among uninsured patients relative to patients who chose not to enroll. Methods: Multiple time series analysis was performed to examine rates of ED utilization and inpatient admission among TAP patients and a comparison group of eligible patients who did not join (non-TAP patients). Monthly ED utilization and inpatient admission rates for both groups were examined prior to and subsequent to referral to TAP, within a study period 2007-2011. Results: During the study period, 623 patients were eligible to enroll, and 374 joined the program. Rates of ED visits per month increased in both groups. Compared with non-TAP patients, TAP patients had 2.0 fewer ED visits not leading to admission per 100 patient-months post-TAP ( P = .03, 95% confidence interval = 0.2-3.9). TAP status was a moderate predictor of ED visits not leading to admission, after controlling for age, gender, and zip code ( P = .04, 95% confidence interval = 0.1-3.9). Conclusions: Although overall ED utilization did not change significantly between program participants and nonparticipants, TAP patients had a lower rate of ED visits not resulting in inpatient admission relative to the comparison group.

Naloxone in ultralow concentration restores endomorphin-1-evoked Ca²⁺ signaling in lipopolysaccharide pretreated astrocytes

Long-term pain is a disabling condition that affects thousands of people. Pain may be sustained for a long time even after the physiological trigger has resolved. Possible mechanisms for this phenomenon include low-grade inflammation in the CNS. Astrocytes respond to inflammatory stimuli and may play an important role as modulators of the inflammatory response in the nervous system. This study aimed first to assess how astrocytes in a primary culture behave when exposed to the endogenous μ-opioid receptor agonist endomorphin-1 (EM-1), in a concentration-dependent manner, concerning intracellular Ca²⁺ responses. EM-1 stimulated the μ-opioid receptor from 10⁻¹⁵ M up to 10⁻⁴ M with increasing intensity, usually reflected as one peak at low concentrations and two peaks at higher concentrations. Naloxone, pertussis toxin (PTX), or the μ-opioid receptor antagonists CTOP did not totally block the EM-1-evoked Ca²⁺ responses. However, a combination of ultralow concentration naloxone (10⁻¹² M) and PTX (100 ng/ml) totally blocked the EM-1-evoked Ca²⁺ responses. This suggests that ultralow (picomolar) concentrations of naloxone should block the μ-opioid receptor coupled G(s) protein, and that PTX should block the μ-opioid receptor coupled G(i/o) protein. The second aim was to investigate exposure of astrocytes with the inflammatory agent lipopolysaccharide (LPS). After 4 h of LPS incubation, the EM-1-evoked Ca²⁺ transients were attenuated, and after 24 h of LPS incubation, the EM-1-evoked Ca²⁺ transients were oscillated. To restore the EM-1-evoked Ca²⁺ transients, naloxone was assessed as a proposed anti-inflammatory substance. In ultralow picomolar concentration, naloxone demonstrated the ability to restore the Ca²⁺ transients.