Journal of General Internal Medicine

Attending rounds remain the primary venue for formal teaching and learning at academic medical centers. Little is known about the effect of increasing clinical demands on teaching during attending rounds. To explore the relationships among teaching time, teaching topics, clinical workload, and patient complexity variables. Observational study of medicine teaching teams from September 2008 through August 2014. Teams at two large teaching hospitals associated with a single medical school were observed for periods of 2 to 4 weeks. Twelve medicine teaching teams consisting of one attending, one second- or third-year resident, two to three interns, and two to three medical students. The study examined relationships between patient complexity (comorbidities, complications) and clinical workload variables (census, turnover) with educational measures. Teams were clustered based on clinical workload and patient complexity. Educational measures of interest were time spent teaching and number of teaching topics. Data were analyzed both at the daily observation level and across a given patient’s admission. We observed 12 teams, 1994 discussions (approximately 373 h of rounds) of 563 patients over 244 observation days. Teams clustered into three groups: low patient complexity/high clinical workload, average patient complexity/low clinical workload, and high patient complexity/high clinical workload. Modest associations for team, patient complexity, and clinical workload variables were noted with total time spent teaching (9.1% of the variance in time spent teaching during a patient’s admission; F[8,549] = 6.90, p < 0.001) and number of teaching topics (16% of the variance in the total number of teaching topics during a patient’s admission; F[8,548] = 14.18, p < 0.001). Clinical workload and patient complexity characteristics among teams were only modestly associated with total teaching time and teaching topics.

Due to risk for treatment-related late effects and concerns about cancer recurrence, long-term cancer survivors have unique medical needs. Survivors’ preferences for care may influence adherence and care utilization. To describe survivors’ preferences for care and factors associated with preferred and actual care. Cross-sectional analysis of participants in a longitudinal study using mailed questionnaires. Survivors of ten common cancers (n = 2,107, mean years from diagnosis 8.9). (1) Survivors’ preferences for primary care physician (PCP) and oncologist responsibilities across four types of care: cancer follow-up, cancer screening, preventive health, and comorbid conditions. (2) Survivor-reported visits to PCPs and oncologists. The response rate was 42.1%. Most long-term survivors preferred PCPs and oncologists share care for cancer follow-up (63%) and subsequent screening (65%), while preferring PCP-led preventive health (77%) and comorbid condition (83%) care. Most survivors (88%) preferred oncologists involved in cancer follow-up care, but only 60% reported an oncologist visit in the previous 4 years, and 96% reported a PCP visit in the previous 4 years. In multivariable regressions, those with higher fear of cancer recurrence were less likely to prefer PCP-led cancer follow-up care (OR = 0.96, CI = 0.93–0.98), as did survivors with advanced cancer stage (OR = 0.56, CI = 0.39–0.79). Those with higher fear of recurrence (OR = 1.03, CI = 1.01–1.04) or who preferred oncologist-led cancer follow-up care (OR = 2.08, CI = 1.63–2.65) had greater odds of seeing an oncologist in the last 4 years. Most cancer survivors preferred PCPs and oncologists share care for cancer follow-up and screening, yet many had not seen an oncologist recently. Survivors preferred PCP-led care for other preventive services and management of comorbid conditions. These findings highlight the important role PCPs could play in survivor care, suggesting the need for PCP-oriented education and health system policies that support high-quality PCP-led survivor care.

Objective:To evaluate the preparation and interpretation of sputum Gram stains by housestaff physicians in the assessment of patients with community-acquired pneumonia. Design:A prospective, multicenter study. Setting:Two university-affiliated hospitals in Pittsburgh. Patients:Ninety-nine cases of clinically and radiographically established pneumonia occurring in 97 patients. Diagnostic test assessment:Housestaff and microbiology personnel prepared a Gram stain for each case of pneumonia. Housestaff assessed the presence and identity of a predominant microbial organism on the slides they prepared. Two senior staff microbiologists, blinded to patient and preparer, evaluated all slides for preparation, sputum purulence, and identification of the predominant organism. Two reference standards were used to assess the sensitivity, specificity, and predictive values of housestaff’s Gram-stain interpretations: 1) senior staff microbiologists’ determinations of the microbes present using the slides without benefit of culture results, and 2) the etiologic agent derived from results of sputum culture, blood culture, or serology. Measurements and main results:Housestaff physicians completed a Gram stain in 58% of the pneumonia episodes. Gram stains were not made in 42% of cases, primarily because patients were unable to produce sputum. Fifteen percent of housestaff’s smears were judged inadequately prepared, compared with 3% for the laboratory personnel (p<0.01). Housestaff obtained purulent sputum samples significantly more often than did nursing personnel (58% versus 38%; p<0.01). Housestaff’s Gram stains were 90% sensitive for detecting pneumococcus, with a 50% falsepositive rate. The sensitivity of the Gram stain was less for identification of Haemophilus influenzaethan for identification of Streptococcus pneumoniae.A single antimicrobial agent was chosen as initial therapy for 50% of the patients in whom housestaff identified a predominant organism, compared with 30% in whom a predominant organism was not identified (p≤0.05). Conclusions:Although housestaff obtained purulent sputum samples more frequently than did nursing personnel, they made systematic errors in the preparation and interpretation of Gram-stained slides. Housestaff physicians should receive formal training in the preparation and interpretation of Gram stains; the specific defects elucidated in this study warrant special attention.

Mặc dù đã có nhiều mô tả về những rào cản đối với sức khỏe của bác sĩ, nhưng các giải pháp cụ thể thì vẫn thiếu. Chúng tôi đã tìm đến những chuyên gia từ các lĩnh vực đa dạng mà công việc của họ yêu cầu sự gắn kết và kết nối giữa cá nhân với khách hàng. Mục tiêu là xác định những chiến lược hiệu quả từ các lĩnh vực không phải y tế có thể áp dụng để bảo vệ sức khỏe của bác sĩ. Chúng tôi đã tiến hành phỏng vấn bán cấu trúc với 30 chuyên gia bên ngoài lĩnh vực y khoa lâm sàng, những người có công việc liên quan đến việc tạo dựng các kết nối hiệu quả với cá nhân. Các chuyên gia đến từ nhiều nghề khác nhau, bao gồm dịch vụ bảo vệ (ví dụ: cảnh sát, lính cứu hỏa), kinh doanh/tài chính (ví dụ: chủ nhà hàng, nhân viên bán hàng), quản lý (ví dụ: giám đốc điều hành, hiệu trưởng), giáo dục, nghệ thuật/thiết kế/giải trí (ví dụ: nhạc sĩ chuyên nghiệp, nhà làm phim tài liệu), dịch vụ cộng đồng/xã hội (ví dụ: nhân viên xã hội, linh mục), và dịch vụ chăm sóc cá nhân (ví dụ: nhà trị liệu mát-xa, huấn luyện viên yoga). Các cuộc phỏng vấn đã đề cập đến những chiến lược mà các chuyên gia sử dụng để khởi xướng và duy trì mối quan hệ, các thực hành nuôi dưỡng sự hài lòng nghề nghiệp và gìn giữ sức khỏe, và các kỹ thuật giúp tạo ra sự hiện diện cảm xúc trong các tương tác. Dữ liệu được mã hóa bằng phương pháp phân tích chủ đề cảm inductive. Các chuyên gia đã xác định các chiến lược chăm sóc bản thân ở cả cấp độ thể chế và cá nhân để hỗ trợ sức khỏe. Các chiến lược ở cấp độ thể chế bao gồm việc lên lịch cho phép chăm sóc bản thân, thời gian được bảo vệ để kết nối với đồng nghiệp, và sự hỗ trợ từ lãnh đạo trong việc giải thích sau những sự kiện chấn thương. Các chiến lược cá nhân bao gồm các kỹ thuật bảo vệ cảm xúc và tham gia vào một cuộc trao đổi hai chiều, là cốt lõi của sự kết nối giữa cá nhân và sự thỏa mãn nghề nghiệp. Trong nghiên cứu khám phá này, kỹ thuật lấy mẫu có mục đích và một đại diện cho mỗi nghề có thể hạn chế khả năng tổng quát của các phát hiện. Qua nhiều lĩnh vực khác nhau, các chuyên gia sử dụng những chiến lược chăm sóc sức khỏe chung ở cả cấp độ thể chế và cá nhân, tạo điều kiện cho sự gắn kết có ý nghĩa, hỗ trợ sự đồng nghiệp, và khuyến khích quá trình xử lý sau những sự kiện căng thẳng. Tính liên ngành của những chiến lược sức khỏe này nhấn mạnh các nền tảng phổ quát hỗ trợ sức khỏe cho những người tham gia vào các nghề có định hướng con người.

BACKGROUND: Internal medicine residents must be competent in advanced cardiac life support (ACLS) for board certification. OBJECTIVE: To use a medical simulator to assess postgraduate year 2 (PGY-2) residents’ baseline proficiency in ACLS scenarios and evaluate the impact of an educational intervention grounded in deliberate practice on skill development to mastery standards. DESIGN: Pretest-posttest design without control group. After baseline evaluation, residents received 4, 2-hour ACLS education sessions using a medical simulator. Residents were then retested. Residents who did not achieve a research-derived minimum passing score (MPS) on each ACLS problem had more deliberate practice and were retested until the MPS was reached. PARTICIPANTS: Forty-one PGY-2 internal medicine residents in a university-affiliated program. MEASUREMENTS: Observational checklists based on American Heart Association (AHA) guidelines with interrater and internal consistency reliability estimates; deliberate practice time needed for residents to achieve minimum competency standards; demographics; United States Medical Licensing Examination Step 1 and Step 2 scores; and resident ratings of program quality and utility. RESULTS: Performance improved significantly after simulator training. All residents met or exceeded the mastery competency standard. The amount of practice time needed to reach the MPS was a powerful (negative) predictor of posttest performance. The education program was rated highly. CONCLUSIONS: A curriculum featuring deliberate practice dramatically increased the skills of residents in ACLS scenarios. Residents needed different amounts of training time to achieve minimum competency standards. Residents enjoy training, evaluation, and feedback in a simulated clinical environment. This mastery learning program and other competency-based efforts illustrate outcome-based medical education that is now prominent in accreditation reform of residency education.

Machine translation (MT) apps are used informally by healthcare professionals in many settings, especially where interpreters are not readily available. As MT becomes more accurate and accessible, it may be tempting to use MT more widely. Institutions and healthcare professionals need guidance on when and how these applications might be used safely and how to manage potential risks to communication. Explore factors that may hinder or facilitate communication when using voice-to-voice MT. Health professionals volunteered to use a voice-to-voice MT app in routine encounters with their patients. Both health professionals and patients provided brief feedback on the experience, and a subset of consultations were observed. Doctors, nurses, and allied health professionals working in the Primary Care Division of the Geneva University Hospitals, Switzerland. Achievement of consultation goals; understanding and satisfaction; willingness to use MT again; difficulties encountered; factors affecting communication when using MT. Fourteen health professionals conducted 60 consultations in 18 languages, using one of two voice-to-voice MT apps. Fifteen consultations were observed. Professionals achieved their consultation goals in 82.7% of consultations but were satisfied with MT communication in only 53.8%. Reasons for dissatisfaction included lack of practice with the app and difficulty understanding patients. Eighty-six percent of patients thought MT-facilitated communication was easy, and most participants were willing to use MT in the future (73% professionals, 84% patients). Experiences were more positive with European languages. Several conditions and speech practices were identified that appear to affect communication when using MT. While professional interpreters remain the gold standard for overcoming language barriers, voice-to-voice MT may be acceptable in some clinical situations. Healthcare institutions and professionals must be attentive to potential sources of MT errors and ensure the conditions necessary for safe and effective communication. More research in natural settings is needed to inform guidelines and training on using MT in clinical communication.

Different conceptual frameworks guide how an organization can change its policies and practices to make care and outcomes more equitable for patients, and how the organization itself can become more equitable. Nonetheless, healthcare organizations often struggle with implementing these frameworks. To assess what guidance frameworks for health equity provide for organizations implementing interventions to make care and outcomes more equitable. Fourteen inequity frameworks from scoping literature review 2000–2017 that provided models for improving disparities in quality of care or outcomes were assessed. We analyzed how frameworks addressed key implementation factors: (1) outer and inner organizational contexts; (2) process of translating and implementing equity interventions throughout organizations; (3) organizational and patient outcomes; and (4) sustainability of change over time. We conducted member check interviews with framework authors to verify our assessments. Frameworks stressed assessing the organization’s outer context, such as population served, for tailoring change strategies. Inner context, such as existing organizational culture or readiness for change, was often not addressed. Most frameworks did not provide guidance on translation of equity across multiple organizational departments and levels. Recommended evaluation metrics focused mainly on patient outcomes, leaving organizational measures unassessed. Sustainability was not addressed by most frameworks. Existing equity intervention frameworks often lack specific guidance for implementing organizational change. Future frameworks should assess inner organizational context to guide translation of programs across different organizational departments and levels and provide specific guidelines on institutionalization and sustainability of interventions.

Emerging health care research paradigms such as comparative effectiveness research (CER), patient-centered outcome research (PCOR), and precision medicine (PM) share one ultimate goal: constructing evidence to provide the right treatment to the right patient at the right time. We argue that to succeed at this goal, it is crucial to have both timely access to individual-level data and fine geographic granularity in the data. Existing data will continue to be an important resource for observational studies as new data sources are developed. We examined widely used publicly funded health databases and population-based survey systems and found four ways they could be improved to better support the new research paradigms: (1) finer and more consistent geographic granularity, (2) more complete geographic coverage of the US population, (3) shorter time from data collection to data release, and (4) improved environments for restricted data access. We believe that existing data sources, if utilized optimally, and newly developed data infrastructures will both play a key role in expanding our insight into what treatments, at what time, work for each patient.