Search

Although keeping patients informed is a part of quality hospital care, inpatients often report they are not well informed. The authors placed whiteboards in each patient room on medicine wards in their hospital and asked nurses and physicians to use them to improve communication with inpatients. The authors then examined the effect of these whiteboards by comparing satisfaction with communication of patients discharged from medical wards before and after whiteboards were placed to satisfaction with communication of patients from surgical wards that did not have whiteboards. Patient satisfaction scores (0-100 scale) with communication improved significantly on medicine wards: nurse communication (+6.4, P < .001), physician communication (+4.0, P = .04), and involvement in decision making (+6.3, P = .002). Patient satisfaction scores did not change significantly on surgical wards. There was no secular trend, and the authors excluded a trend in overall patient satisfaction. Whiteboards could be a simple and effective tool to increase inpatient satisfaction with communication. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Accreditation Council for Graduate Medical Education's new duty-hour standards limit interns' shifts to 16 hours and night float to 6 consecutive nights. Protected sleep time (that is, 'nap') is strongly encouraged. As duty-hour reforms are implemented, examination of the quality and outcomes of the relevant literature is important. PURPOSE: To systematically review the literature examining shift length, protected sleep time, and night float. DATA SOURCES: MEDLINE, PREMEDLINE, and EMBASE from January 1989 through May 2010. STUDY SELECTION: Studies examined the associations of shift length, protected sleep time, or night float with patient care, resident health, and education outcomes among residents in practice settings. DATA EXTRACTION: Study quality was measured by using the validated Medical Education Research Study Quality Instrument and the U.S. Preventive Services Task Force criteria. Two investigators independently rated study quality, and interrater agreement was calculated. DATA SYNTHESIS: Sixty-four studies met inclusion criteria. Most studies used single-group cross-sectional (19 studies [29.7%]) or pre-post (41 studies [64.1%]) designs, and 4 (6.3%) were randomized, controlled trials. Five studies (7.8%) were multi-institutional. Twenty-four of 33 (72.7%) studies examining shift length reported that shorter shifts were associated with decreased medical errors, motor vehicle crashes, and percutaneous injuries. Only 2 studies assessed protected sleep time and reported that residents' adherence to naps was poor. Night floats described in 33 studies involved 5 to 7 consecutive nights. LIMITATIONS: Most studies used single-institution, observational designs. Publication bias is likely but difficult to assess in this methodologically weak and heterogeneous body of evidence. CONCLUSION: For the limited outcomes measured, most studies supported reducing shift length but did not adequately address the optimal shift duration. Studies had numerous methodological limitations and unclear generalizability for most outcomes. Specific recommendations about shift length, protected sleep time, and night float should acknowledge the limitations of this evidence. PRIMARY FUNDING SOURCE: Accreditation Council for Graduate Medical Education. [ABSTRACT FROM AUTHOR]

Background: Although it may take up relatively little time, hospitalized patients' interactions with their physicians are important elements of their hospital experience. Purpose: We conducted a qualitative study to explore what is important to patients about bedside interactions with their physician teams. Methods: We interviewed medical inpatients and used grounded theory methodology to analyze interview transcripts. Results: We recruited 17 patients from an academic medical center including a university hospital and a Veterans Administration (VA) hospital.We found that important aspects of patient-team interactions included the exchange of information, evidence of caring from their team, involvement in teaching, knowing the team members, and bedside manner. Patients also described team characteristics that were important to them such as team attributes and intrateam collaboration. Conclusions: This model clarifies the aspects of bedside interactions that patientsvalue and will allow physicians to focus their limited time to the benefit of their patients. [ABSTRACT FROM AUTHOR]

Context: The Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003, partly out of concern for residents' well-being in the setting of sleep deprivation. These limitations are likely to also have an impact on other aspects of the lives of residents.Objective: To summarize the literature regarding the effect of interventions to reduce resident work hours on residents' education and quality of life.Data Sources: We searched the English-language literature about resident work hours from 1966 through April 2005 using MEDLINE, EMBASE, and Current Contents, supplemented with hand-search of additional journals, reference list review, and review of abstracts from national meetings.Study Selection: Studies were included that assessed a system change designed to counteract the effects of resident work hours, fatigue, or sleep deprivation; included an outcome directly related to residents; and were conducted in the United States.Data Extraction: For each included study, 2 investigators independently abstracted data related to study quality, subjects, interventions, and findings using a standard data abstraction form.Data Synthesis: Fifty-four articles met inclusion criteria. The interventions used to decrease resident work hours varied but included night and day float teams, extra cross-coverage, and physician extenders. Outcomes included measures of resident education (operative experience, test scores, satisfaction) and quality of residents' lives (amount of sleep, well-being). Interventions to reduce resident work hours resulted in mixed effects on both operative experience and on perceived educational quality but generally improved residents' quality of life. Many studies had major limitations in their design or conduct.Conclusions: Past interventions suggest that residents' quality of life may improve with work hour limitations, but interpretation of the outcomes of these studies is hampered by suboptimal study design and the use of nonvalidated instruments. The long-term impact of reducing resident work hours on education remains unknown. Current and future interventions should be evaluated with more rigorous methods and should investigate links between residents' quality of life and quality of patient care. [ABSTRACT FROM AUTHOR]

PURPOSE: To evaluate the Hooked On Nicotine Checklist's (HONC) internal consistency, reliability over time, correlation with self-described smoking behavior, and to compare the results with previous studies of the onset of nicotine dependence in youths. METHODS: Ninth-grade students were recruited from a regional school district. Subjects (Ss; n = 371; 91% of the 9th-grade class) were 48.8% male, 97% white, aged 13.8-15.6 years. Ss self-administered a questionnaire on smoking experiences. The HONC was completed by 88 (23.7%) who had puffed on a cigarette at least once; 74 were retested 2 weeks later. Responding 'yes' to any of the 10 HONC items indicates nicotine dependence (ND); the number of items endorsed indicates the degree of its severity. RESULTS: The internal consistency of the HONC is high overall (alpha = 0.90; n = 88), and test-retest reliability for the entire HONC is excellent (intraclass correlation = 0.88, p <.001). Individual items generally showed good to excellent reliability over time (Median Yules' Y = 0.71, range = 0.41-0.82). HONC scores were strongly correlated with self-reported smoking (r = 0.70, p <.001, n = 88). CONCLUSIONS: Adding the HONC to routine adolescent health examinations, health classes, and prevention programs may make adolescents more aware of their symptoms of ND and enable intervention before ND progresses. [ABSTRACT FROM AUTHOR]

BACKGROUND: One of the most effective methods for teaching physical diagnosis may be standardized patient instructors. PURPOSE: To determine if a lecture plus standardized patient instructors with small-group sessions is more effective than a lecture alone for teaching the evaluation of patients with abdominal pain. METHODS: Control (class of 2001) and intervention (class of 2002) groups both attended a lecture on the abdominal examination. The intervention group then underwent an exercise with standardized patient instructors and a review session with surgical faculty. An evaluation 18 months later used standardized patient instructors to complete evaluations assessing history-taking and physical examination skills. RESULTS: The intervention group performed significantly better than the control group on both the history and the physical examination subscales. CONCLUSION: It is possible to have an important, measurable, and lasting effect on physical examination skills by adding standardized patient instructors and small-group discussion to a lecture presentation. [ABSTRACT FROM AUTHOR]

While work-related upper extremity conditions (WRUECs) cause almost 25% of lost time cases in the US, little is known about their long-term occupational consequences. A self-report survey was mailed to New Hampshire workers reporting a WRUEC one year prior to the study. Of the 72 (52%) valid respondents, 60% had lost > or = 1 week of work and 90% had returned to work. Almost 70% reported acute injury onset, and 26% had experienced a recurrence of their WRUEC. Both gradual-onset injuries and recurrences had worse outcomes. Recurrence was related to shorter job tenure, lower job satisfaction, and less satisfaction with medical care and insurer responses. Results imply that a single measure is insufficient to assess occupational outcomes subsequent to a WRUEC. The importance of secondary prevention was highlighted. There is a need for focus on gradual-onset injuries, as well as those acute-onset injuries with risk for recurrence. [ABSTRACT FROM AUTHOR]

Study Objective: To psychometrically evaluate a cough-specific quality-of-life questionnaire (CQLQ) in adults.Design: Prospective evaluation of CQLQ using three different cohorts of adult subjects with cough.Setting: Academic tertiary-care ambulatory medical facilities.Participants: One hundred fifty-four subjects complaining of chronic cough, 30 of acute cough, and 31 smokers with cough.Interventions: Self-administration of the CQLQ in acute coughers, smokers, and chronic coughers before and after therapy.Measurements: Psychometric analyses including factor analysis (FA), and assessments of reliability and validity.Results: Acute and chronic cough data were subjected to FA, and the Cronbach alpha and interitem correlations were computed. FA of chronic and acute cough data (n = 184) revealed six subscales. The Cronbach alpha for the total CQLQ was 0.92, and it was 0.62 to 0.86 (mean, 0.76) for the six subscales. Interitem correlations for the total CQLQ ranged from -0.06 to 0.72, with a mean of 0.28. Test-retest reliability in 52 chronic coughers demonstrated nonsignificant changes with readministration of the questionnaire, and the intraclass correlation for total CQLQ was 0.89, and for the subscales the range was 0.75 to 0.93. Analysis of variance followed by tests of contrasts among all possible pairings of chronic coughers, acute coughers, and smokers showed significant differences (p < or = 0.001) among the groups. Posttreatment cure scores were significantly lower (p < or = 0.001) than pretreatment scores in 24 chronic coughers.Conclusions: The 28-item CQLQ has dimensionality that is consistent with a cough-specific quality-of-life instrument. It is a valid and reliable method by which to assess the impact of cough on the quality of life of chronic and acute coughers, and the efficacy of cough therapies in chronic coughers. [ABSTRACT FROM AUTHOR]

Data from a mailed survey to primary care physicians (N = 122) were used to construct and evaluate psychosocial scales related to performance of smoking cessation counseling. Scales measuring counseling barriers, self-efficacy, and motivation demonstrated considerable promise with excellent or reasonable internal consistency. The correlation for each scale with performance of cessation counseling and with stage of change was statistically significant. Physicians who report they are currently assisting patients had higher performance and self-efficacy rating. Physicians who had participated in formal smoking cessation training had higher self-efficacy; however, their scores on the Barriers, Motivation, and Performance Scales did not differ. Further study with a representative group is encouraged. [ABSTRACT FROM AUTHOR]

Abstract Background With a goal to reduce youth smoking rates, the U.S. federal government mandated that states enforce laws prohibiting underage tobacco sales. Our objective was to determine if state compliance with tobacco sales laws is associated with a decreased risk of current daily smoking among adolescents. Methods Data on tobacco use were obtained from a nationally representative sample of 16,244 adolescents from the 2003 Monitoring the Future survey. The association between merchant compliance with the law from 1997–2003 and current daily smoking was examined using logistic regression while controlling for cigarette prices, state restaurant smoking policies, anti-tobacco media, and demographic variables. Results Higher average state merchant compliance from 1997–2003 predicted lower levels of current daily smoking among adolescents when controlled for all other factors. The odds ratio for daily smoking was reduced by 2% for each 1% increase in merchant compliance. After controlling for price changes, media campaigns and smoking restrictions, a 20.8% reduction in the odds of smoking among 10th graders in 2003 was attributed to the observed improvement in merchant compliance between 1997 and 2003. A 47% reduction in the odds of daily smoking could be attributed to price increases over this period. Conclusion Federally mandated enforcement efforts by states to prevent the sale of tobacco to minors appear to have made an important contribution to the observed decline in smoking among youth in the U.S. Given similar results from long-term enforcement efforts in Australia, other countries should be encouraged to adopt the World Health Organization Framework on Tobacco Control strategies to reduce the sale of tobacco to minors.

OBJECTIVE: The goal was to evaluate the degree to which a smoking prevention and cessation intervention was delivered by providers to adolescents in the pediatric office setting. METHODS: Eight pediatric clinics in central Massachusetts were assigned randomly to either a special intervention (brief pediatric provider-delivered intervention plus peer counseling) or the usual care condition. Subjects (n = 2710) were adolescents 13 to 17 years of age, both smokers (smoked in the past 30 days) and nonsmokers/former smokers. The degree to which smoking prevention and treatment interventions were delivered by providers was assessed through patient exit interviews with adolescents after their clinic visits; interviews assessed the occurrence of 10 possible intervention steps. RESULTS: The percentage of providers engaging in the smoking interventions differed significantly between the special intervention and usual care conditions, according to adolescent reports in the patient exit interviews. For nonsmokers/former smokers, overall patient exit interview scores were 7.24 for the special intervention condition and 4.95 for the usual care condition. For current smokers, overall patient exit interview scores were 8.40 and 6.24 for the special intervention and usual care conditions, respectively. Intervention fidelity of special intervention providers was 72.2% and 84.0% for nonsmokers/former smokers and current smokers, respectively. CONCLUSIONS: Pediatric providers who receive training and reminders to deliver a brief smoking prevention and cessation intervention to adolescents in the context of routine pediatric primary care practice can do so feasibly and with a high degree of fidelity to the intervention protocol. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to determine if a standardized root cause analysis (RCA2) selection algorithm, developed by the Veterans Affairs, would select high-risk events for RCA., Methods: Physician-entered incident reports for all surgical service admissions and perioperative visits were queried over 12 months in the DATIX Clinical Incident Management System. Independent reviewers assigned potential harm and event frequency scores using an institutional scoring system and then calculated and rounded average scores. These were classified using RCA2 terminology (catastrophic, major, moderate, minor for harm; frequent, occasional, uncommon, remote for frequency). The scores were then evaluated with the standardized Safety Assessment Code Matrix (SAC) algorithm from the National Patient Safety Foundation's RCA2 guidelines to determine Potential Harm Scores. The SAC combines severity and probability to determine the necessity of conducting an RCA. Catastrophic and major high-frequency events (matrix score = 3) were classified as "RCA recommended." The study then compared cases selected for RCAs using the updated RCA2 algorithm against cases selected using a current, institutional-specific RCA selection process., Results: One hundred four cases were reviewed, comprising 20 catastrophic, 48 major harm, 26 moderate harm, and 10 minor harm events. After removing 9 high-variance cases, our institution's current selection process selected 18 cases for RCAs, including 6/20 catastrophic, 8/39 major harm, and 4/36 moderate/minor harm events. Only 17.3% of cases had an RCA completed, while the standardized RCA2 algorithm recommended investigation for 56.7% of patient safety events, based on SAC Matrix scoring. Current RCA selection processes rendered 4 RCAs on low potential harm or low-frequency events, while 45 potential high-frequency, high potential harm events did not complete RCAs., Conclusions: Standardizing the selection of patient safety incidents for RCA using the RCA2 algorithm improves case identification based on the event frequency and potential harm score. Thus, this algorithm has the potential to advance patient safety., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Previous studies exploring difficult inpatients have mostly focused on psychiatric inpatients., Objective: To explore the characteristics of difficult medicine inpatients., Design: Qualitative study using focus groups and semi-structured interviews. Transcripts were recorded, transcribed, and coded (MAXQDA) using thematic content analysis., Participants: Medicine inpatient providers at a tertiary care facility., Key Results: Our sample consisted of 28 providers (6 hospitalists, 10 medicine attendings, 6 medicine residents, and 6 interns). Theme 1: Provider experience: Difficult inpatients were time-consuming and evoked emotional responses including frustration and dysphoria. Theme 2: Patient characteristics: Included having personality disorders or mental health issues, being uncooperative, manipulative, angry, demanding, threatening, or distrustful. Difficult patients also had challenging social situations and inadequate support, unrealistic care expectations, were self-destructive, tended to split care-team messages, and had unclear diagnoses. Theme 3: Difficult families: Shared many characteristics of difficult patients including being distrustful, demanding, manipulative, threatening, or angry. Difficult families were barriers to care, disagreed with the treatment plan and each other, did not act in the patient's best interest, suggested inappropriate treatment, or had unrealistic expectations., Strategies: Approaches to dealing with difficult patients or families included building trust, being calm, and having a consistent message. Communication approaches included naming the emotion, empathetic listening, identifying patient priorities and barriers, and partnering., Conclusions: Difficult patients induced emotional responses, dysphoria, and self-doubt among providers. Underlying personality disorders were often mentioned. Difficult patients and families shared many characteristics. Communication and training were highlighted as key strategies., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: The benefits of friendships among peers with and without intellectual and developmental disabilities are well supported by research. However, little is known about the nature of these inclusive friendships in inclusive college courses., Method: We explored the perspectives of peers on the development of authentic friendships among peers with and without intellectual and developmental disabilities in inclusive college courses in the United States. We used a sequential, explanatory, transformative mixed methods-grounded theory research design. We integrated quantitative (N = 44) and qualitative (N = 8) findings using blended analysis to inform a preliminary grounded theory of inclusive and reciprocal friendships., Results: Quantitative findings suggest two relationships and one predictor of peers' perceived social engagement. Qualitative findings resulted in five themes that promote friendships., Conclusions: We propose that the context for developing inclusive friendships could be fostered using the preparation and actions stages of the grounded theory model., (© 2024 The Authors. Journal of Applied Research in Intellectual Disabilities published by John Wiley & Sons Ltd.)

Purpose: This study investigates the influence of the COVID-19 pandemic on high school students' interest in health-care careers., Methods: A voluntary web-based survey, approved by the Medical College of Wisconsin's Institutional Review Board, was administered across eight high schools in Milwaukee and its suburbs in Wisconsin. The survey collected students' demographic details, opinions on the health-care system's pandemic response, and their interest in health-care careers before and after the pandemic., Results: Out of 2,949 respondents, 29.9% were already contemplating a health-care career before the pandemic, with 27.7% indicating increased interest thereafter. Students not previously interested in health-care careers registered an 11.5% increase in interest due to the pandemic. Notably, the pandemic significantly boosted health-care career interest among females and freshmen., Discussion: The COVID-19 pandemic has distinctly influenced high school students' interest in health-care careers, notably among females and freshmen. This finding has implications for addressing projected health-care professional shortages., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background Compared to in-person recruitment, virtual interviewing reduces costs and promotes equity. However, many residency applicants believe that visiting programs helps inform their rank decisions. Objective We assessed the feasibility of and stakeholder opinions about optional in-person visits after virtual interviewing and program rank list finalization. Methods Six internal medicine residency programs conducted virtual recruitment in 2022-2023 and finalized their rank lists 4 weeks before the deadline. Applicants were invited for optional in-person visits after program rank list finalization. Interviewed applicants, program directors, and program administrators were given surveys that included 7-17 questions and employed "skip logic," discrete answers (eg, "yes/no/unsure" or multiple choice), and open-ended questions. Survey questions assessed stakeholders' opinions about the value, equity, and potential downsides of this recruitment process. Results Participating programs interviewed an average of 379 applicants (range 205-534) with 39 (10.3% [39 of 379], range 7.9%-12.8% [33 of 420-51 of 397]) applicants completing in-person visits. Of 1808 interviewed applicants, 464 responded to the survey (26%); 88% (407 of 464) believe a similar optional in-person visit should be offered next year, 75% (347 of 464) found this process equitable, but only 56% (258 of 464) trusted programs not to change their rank lists. Nearly all who attended an in-person visit (96.5%, 109 of 113) found it valuable. All program directors liked the optional in-person visit and believe future applicants should be offered similar in-person visits. Conclusions A large majority of participating applicants and program directors believe that in-person visits should be offered after program rank list finalization. The majority of respondents felt this recruitment process was equitable.

Despite the widespread adoption of early warning systems (EWSs), it is uncertain if their implementation improves patient outcomes. The authors report a pre-post quasi-experimental evaluation of a commercially available EWS on patient outcomes at a 700-bed academic medical center. The EWS risk scores were visible in the electronic medical record by bedside clinicians. The EWS risk scores were also monitored remotely 24/7 by critical care trained nurses who actively contacted bedside nurses when a patient's risk levels increased. The primary outcome was inpatient mortality. Secondary outcomes were rapid response team calls and activation of cardiopulmonary arrest (code-4) response teams. The study team conducted a regression discontinuity analysis adjusting for age, gender, insurance, severity of illness, risk of mortality, and hospital occupancy at admission. The analysis included 53,229 hospitalizations. Adjusted analysis showed no significant change in inpatient mortality, rapid response team call, or code-4 activations after implementing the EWS. This study confirms the continued uncertainty in the effectiveness of EWSs and the need for further rigorous examinations of EWSs., (Copyright © 2023 the American College of Medical Quality.)

Patient-physician concordance about topics discussed in a clinic visit is essential for effective communication but may be difficult to achieve in cancer care. We conducted a multicenter, observational study at two Midwestern oncology clinics. A sample of 48 English-speaking or Spanish-speaking women with newly diagnosed stage 0-3 breast cancer completed surveys before and after a visit with an oncologist. Patient-physician dyads were coded as concordant if both patient and physician follow-up self-reports agreed whether (or not) specific treatments were discussed (i.e., treatment option concordance; mastectomy, lumpectomy, hormone therapy, neoadjuvant, and adjuvant chemotherapy) and whether risk was described using certain quantitative formats (i.e., quantitative format concordance; percentages, proportions out of 100 and 1000, graphs, pictures, evidence from clinical studies, cancer stage). Agreement was determined using percent agreement and prevalence-adjusted bias-adjusted kappa (PABAK). Pearson's correlations were used to determine relationships between anxiety and each measure concordance. Percent concordance was higher for treatment concordance (73.3%) compared to quantitative format concordance (64.5%), and PABAK scores tended to be higher for treatment options (PABAK = .21-.78). Both treatment and quantitative format concordance were negatively associated with pre-visit state anxiety, but only treatment concordance was statistically significant (treatment: r =  - .504, p = .001; quantitative format: r =  - .096, p = .523). Our study indicates moderate patient-physician concordance in early breast cancer care communication and that patient anxiety may impact the ability for patients and physicians to agree on the content communicated in a clinic visit., (© 2021. American Association for Cancer Education.)

Background: Residents have valuable perspectives about diversity and equity in medical training, yet many graduate medical education curricula lack dedicated activities focused on such issues., Objectives: To describe and report feasibility and acceptability of an innovation that uses individual reflection and group discussion to create conversation in our residency program about equity and injustice through the lens of the Black Lives Matter movement., Methods: In July 2020, we sent a survey with reflection prompts to all postgraduate year 2 and above internal medicine residents. In the discussion session (during required academic time), we presented 10 of the residents' responses to the reflection prompts. After each response was read aloud, the residents had an open discussion. We used thematic analysis to analyze the responses to the reflection prompts. Acceptability was tracked through free-text comments in the survey. Feasibility was measured by the time and resources needed to conduct the session., Results: We received responses from 24 out of 72 (33%) residents. We identified 10 codes that fell into 4 themes. The most commonly identified codes included anger or frustration toward events, self-reflection on privilege, increased awareness and discussion of racism in daily life, and life being minimally impacted/homeostasis. The 4 overarching themes were (1) awareness, (2) motivation for change, (3) emotional response, and (4) self-reflection., Conclusions: Using a format of reflection and sharing of anonymous responses was an inexpensive and effective method to begin a discussion about equity and injustice in medicine., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background: Unrecognised changes in a hospitalised patient's clinical course may lead to a preventable adverse event. Early warning systems (EWS) use patient data, such as vital signs, nursing assessments and laboratory values, to aid in the detection of early clinical deterioration. In 2018, an EWS programme was deployed at an academic hospital that consisted of a commercially available EWS algorithm and a centralised virtual nurse team to monitor alerts. Our objective was to understand the nursing perspective on the use of an EWS programme with centralised monitoring., Methods: We conducted and audio-recorded semistructured focus groups during nurse staff meetings on six inpatient units, stratified by alert frequency (high: >100 alerts/month; medium: 50-100 alerts/month; low: <50 alerts/month). Discussion topics included EWS programme experiences, perception of EWS programme utility and EWS programme implementation. Investigators analysed the focus group transcripts using a grounded theory approach., Results: We conducted 28 focus groups with 227 bedside nurses across all shifts. We identified six principal themes: (1) Alert timeliness, nurses reported being aware of the patient's deterioration before the EWS alert, (2) Lack of accuracy, nurses perceived most alerts as false positives, (3) Workflow interruptions caused by EWS alerts, (4) Questions of actionability of alerts, nurses were often uncertain about next steps, (5) Concerns around an underappreciation of core nursing skills via reliance on the EWS programme and (6) The opportunity cost of deploying the EWS programme., Conclusion: This qualitative study of nurses demonstrates the importance of earning user trust, ensuring timeliness and outlining actionable next steps when implementing an EWS. Careful attention to user workflow is required to maximise EWS impact on improving hospital quality and patient safety., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Morning report is one of the central activities of internal medicine residency education. The two most common morning report formats are scripted reports, which use preselected cases with prepared didactics, and unscripted reports in which a case is discussed without preparation. No previous study has compared these two formats., Methods: We conducted a prospective observational study of morning report conducted at 10 academic medical centers across the United States., Results: A total of 198 case-based morning reports were observed. Of these, 169 (85%) were scripted and 29 (15%) were unscripted. Scripted reports were more likely to present a case with a known final diagnosis (89% vs 76%, P = 0.04), use electronic slides (76% vs 52%, P = 0.01), involve more than 15 slides (55% vs 3%, P < 0.001), and reference the medical literature (61% vs 34%, P = 0.02), including professional guidelines (32% vs 10%, P = 0.02) and original research (25% vs 0%, P = 0.001). Scripted reports also consumed more time in prepared didactics (8.0 vs 0 minutes, P < 0.001). Unscripted reports consumed more time in case history (10.0 vs 7.0 minutes, P < 0.001), physical examination (3.0 vs 2.0 minutes, P = 0.06), and differential diagnosis (10.0 vs 7.0 minutes, P = 0.01)., Conclusions: Most contemporary morning reports are scripted. Compared with traditional unscripted reports, scripted reports are more likely to involve a case with a known diagnosis, use extensive electronic presentation slides, and consume more time in didactics, while unscripted reports consume more time in the early diagnostic process, including history, physical examination, and differential diagnosis. Residency programs interested in emphasizing these aspects of medical education should encourage unscripted morning reports.

The cognitive autopsy has been a proposed tool for physicians to evaluate misdiagnosis. However, prior iterations of this tool are cumbersome, not designed for the internist, and may cause users to isolate cognition from systems issues. A 10-point tool was created to be utilized individually or by a group when evaluating an adverse event. This could be used with Croskerry's 2020 "cognitive autopsy" or as a standalone tool for internists. We trialed this tool in large group formats and with individual residents; all reported an improved appreciation of the factors leading to poor outcomes and medical errors., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Berlin et al.)

Background: Interprofessional training for patient safety is essential in developing leaders and advocates who are versed in patient safety science and interprofessional collaboration. We describe an interprofessional patient safety fellowship program and its outcomes over 8 years., Methods: Programmatic data were reviewed and a survey was sent to all program graduates with a known email address (N = 18)., Results: Fellows obtained interprofessional skills, knowledge, and methods of patient safety science, as well as preparation as patient safety experts through didactic and experiential training. Program outcomes included sustained quality improvements, publications (n = 8), presentations (n = 29), and recruitment of graduates into quality and safety leadership positions (67%)., Discussion: Facilitators and barriers that influenced the success of the fellowship program were noted at institutional and individual levels. The development and sustainability of interprofessional safety training programs depends on concerted efforts by leadership, academic-practice partnerships, and committed faculty and learners., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Objective: Professional medical interpreters facilitate patient understanding of illness, prognosis, and treatment options. Facilitating end of life discussions can be challenging. Our objective was to better understand the challenges professional medical interpreters face and how they affect the accuracy of provider-patient communication during discussions of end of life., Methods: We conducted semi-structured interviews with professional Spanish medical interpreters. We asked about their experiences interpreting end of life discussions, including questions about values, professional and emotional challenges interpreting these conversations, and how those challenges might impact accuracy. We used a grounded theory, constant comparative method to analyze the data. Participants completed a short demographic questionnaire., Results: Seventeen Spanish language interpreters participated. Participants described intensive attention to communication accuracy during end of life discussions, even when discussions caused emotional or professional distress. Professional strains such as rapid discussion tempo contributed to unintentional alterations in discussion content. Perceived non-empathic behaviors of providers contributed to rare, intentional alterations in discussion flow and content., Conclusion: We found that despite challenges, Spanish language interpreters focus intensively on accurate interpretation in discussions of end of life., Practice Implications: Provider training on how to best work with interpreters in these important conversations could support accurate and empathetic interpretation., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Peripherally inserted central catheters (PICCs) provide reliable intravenous access for delivery of parenteral therapy. Yet, little is known about PICC care practices or how they vary across hospitals. We compared PICC-related processes across hospitals with different insertion delivery models., Methods: We used a descriptive qualitative methodology and a naturalist philosophy, with site visits to conduct semistructured interviews completed between August 2018 and January 2019. Study sites included five Veterans Affairs Medical Centres, two with vascular access teams (VATs), two with PICC insertion primarily by interventional radiology (IR) and one without on-site PICC insertion capability. Interview participants were healthcare personnel (n=56), including physicians, bedside and vascular access nurses, and IR clinicians. Data collection focused on four PICC domains: use and decision-making process, insertion, in-hospital management and patient discharge education. We used rapid analysis and a summary matrix to compare practices across sites within each domain., Results: Our findings highlight the benefits of dedicated VATs across all PICC-related process domains, including implementation of criteria to guide PICC placement decisions, timely PICC insertion, more robust management practices and well-defined patient discharge education. We also found areas with potential for improvement, such as clinician awareness of PICC appropriateness criteria and alternative devices, deployment of VATs and patient discharge education., Conclusion: Vascular access nurses play critical roles in all aspects of PICC-related care. There is variation in PICC decision-making, care and maintenance, and patient education across hospitals. Quality and safety improvement opportunities to reduce this variation are highlighted., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Single-center studies have reported residents experience barriers to accessing supervising physicians overnight, but no national dataset has described barriers perceived by residents or the association between supervision models and perceived barriers., Objective: To explore residents' perception of barriers to accessing overnight supervision., Design: Questions about overnight supervision and barriers to accessing it were included on the American College of Physicians Internal Medicine In-Training Examination® (IM-ITE®) Resident Survey in Fall 2017., Participants: All US-based internal medicine residents who completed the 2017 IM-ITE®. Responses from 20,744 residents (84%) were analyzed., Main Measures: For our main outcome, we calculated percentages of responses for eight barriers and tested for association with the presence or absence of nocturnists. For our secondary outcome, we categorized free-text responses enumerating barriers from all residents into the five Systems Engineering Initiative for Patient Safety (SEIPS) categories to elucidate future areas for study or intervention., Key Results: Internal medicine residents working in hospitals without nocturnists more commonly reported having at least one barrier to accessing a supervising physician "always" or "most of the time" (5075/9842, 51.6%) compared to residents in hospitals with nocturnists (3074/10,902, 28.2%, p < 0.001). Among residents in hospitals without nocturnists, the most frequently reported barrier to accessing attending supervision was attendings not being present in the hospital (30.4% "always" or "most of the time"); residents in hospitals with nocturnists most frequently reported desire to make their own decisions as a barrier to contacting attendings (15.7% "always" or "most of the time"). Free-text responses from residents with and without nocturnists most commonly revealed organization (47%) barriers to accessing supervision; 28% cited person barriers, and 23% cited tools/technology barriers., Conclusions: Presence of nocturnists is associated with fewer reported barriers to contacting supervising physicians overnight. Organizational culture, work schedules, desire for independence, interpersonal interactions, and technology may present important barriers., (© 2021. Society of General Internal Medicine.)

Posttraumatic stress disorder (PTSD) is common in the United States, with a prevalence of nearly 8% in the general population and between 10% and 30% in veterans. Despite how common PTSD is, inpatient providers may not be familiar with its manifestations or feel comfortable taking care of patients who may exhibit symptoms related to it. In our combined experience as VA-based hospital medicine care providers, we have cared for thousands of patients hospitalized for a primary medical condition who also have PTSD as a comorbidity. We have noticed in our practices that we only focus our attention on PTSD if a related problem arises during a patient's hospitalization (eg, confrontations with the care team or high levels of anxiety). We contend that a more proactive approach could lead to better care, but little evidence about best practices exists to inform the interdisciplinary team how to optimally care for hospitalized medical patients with PTSD. In this narrative review, we present a synthesis of existing literature, describe how trauma-informed care could be used to guide the approach to patients with PTSD, and generate ideas for changes that inpatient providers could implement now, such as engaging patients to prevent PTSD exacerbations and promoting better sleep in the hospital.

Background: There are more than five hundred internal medicine residency programs in the USA, involving 27,000 residents. Morning report is a central educational activity in resident education, but no recent studies describe its format or content., Objective: To describe the format and content of internal medicine morning reports., Design and Participants: Prospective observational study of morning reports occurring between September 1, 2018, and April 30, 2019, in ten different VA academic medical centers in the USA., Main Measures: Report format, number and type of learner, number and background of attending, frequency of learner participation, and the type of media used. Content areas including quality and safety, high-value care, social determinants of health, evidence-based medicine, ethics, and bedside teaching. For case-based reports, the duration of different aspects of the case was recorded, the ultimate diagnosis when known, and if the case was scripted or unscripted., Results: A total of 225 morning reports were observed. Reports were predominantly case-based, moderated by a chief resident, utilized digital presentation slides, and involved a range of learners including medicine residents, medical students, and non-physician learners. The most common attending physician present was a hospitalist. Reports typically involved a single case, which the chief resident reviewed prior to report and prepared a teaching presentation using digital presentation slides. One-half of cases were categorized as either rare or life-threatening. The most common category of diagnosis was medication side effects. Quality and safety, high-value care, social determinants of health, and evidence-based medicine were commonly discussed. Medical ethics was rarely addressed., Conclusions: Although a wide range of formats and content were described, internal medicine morning report most commonly involves a single case that is prepared ahead of time by the chief resident, uses digital presentation slides, and emphasizes history, differential diagnosis, didactics, and rare or life-threatening diseases.

During training, fellows serve as teachers and role models for junior colleagues. Fellows-as-teachers curricula may support these roles, but little is known about their effectiveness and durability. We sought to measure the long-term effects on ICU rounds after administering fellows-as-teachers workshops., Design: Prospective pre-/postintervention observational study of ICU rounds., Setting: Tertiary-care medical ICU with both pulmonary critical care and critical care medicine fellowships., Subjects: ICU teaching teams., Interventions: Fellows attended immersive workshops on promoting clinical reasoning, managing the learning environment, teaching bedside skills, and developing situational awareness on ICU rounds. After the workshops, faculty physicians were encouraged to have fellows routinely lead afternoon rounds., Measurements and Main Results: We gathered data from direct observations of ICU rounding activities, residents' evaluations of rounds from surveys, and faculty physicians' written comments on fellows' performance in the ICU from end-of-rotation evaluations. Data were analyzed using descriptive statistics, nonparametric comparative tests, and chi-square tests for categorical data. A total of 61 ICU rounding sessions were observed with 501 discrete provider-patient interactions. Survey responses were collected from a total of 53 residents preintervention and 34 residents postintervention. We reviewed 72 open-ended faculty comments on fellows' end-of-rotation evaluations, with 22 occurring postintervention. During the postintervention period, fellows were significantly more likely to make clinical decisions, explain their reasoning, provide teaching points, and ask questions on rounds. Additionally, we observed significantly higher quality written feedback on end-of-rotation evaluations by faculty physicians. However, residents generally harbored neutral or negative perceptions about the educational value of fellow-led rounds postintervention., Conclusions: Fellows' contributions to patient care and teaching on ICU rounds increased for several months after our fellows-as-teachers workshops. Despite limitations and contamination in our design, our data suggest that similarly designed curricula may promote fellow engagement, possibly at the expense of residents' education., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objective: Medical students and residents face high rates of burnout. Drawing comics may help trainees process their experiences and feel both valued and connected to those who read their work. In this study, the authors sought to elucidate the predominant emotions and themes conveyed in medical students' and residents' comics about stressful situations., Methods: In 10 different sessions, medical trainees drew "something stressful in medicine". Collected comics were analyzed by three coders, who applied emotional adjectives. Differences were resolved through discussion, with one to two final codes per comic. Codes coded based on items objectively seen in the comic and were encouraged not to project what they would feel in that situation., Results: Two hundred ninety comics were analyzed by our research group. "Overwhelmed" was the most common final code (101 comics, 34.8%). Other common adjectives used by our coders to describe the comics were "inadequate" (24, 8.2%), "frustrated" (21, 7.2%), and "helpless" (16, 5.5%). Twelve of the comics (4%) were considered non-codable because of difficulty deciphering the theme or print., Conclusions: Brief comic exercises allowed medical trainees to convey what it is like to be "stressed out" in medical training-with trainees most often showing that they are/feel "overwhelmed," "inadequate," "frustrated," and "helpless." This demonstrates that medical students and residents convey these same emotions when reflecting on individual stressful experiences throughout their training. More research on whether graphic medicine for emotional and cognitive processing of stress makes an impact on burnout and satisfaction is warranted.

Background: Sexual harassment of women is a pervasive problem. Prior studies found that sexual harassment of female providers by patients is common, but guidance on addressing this problem is limited., Objective: To understand the experiences of female providers with sexual harassment by patients with a focus on how practicing providers address these events., Design: Qualitative study using semi-structured interviews., Participants: Twenty female, internal medicine providers, including resident physicians, staff physicians, and nurse practitioners at a large, urban, academic hospital in the USA., Approach: Interviews were analyzed for themes., Key Results: Two themes were explored: first, the experiences with sexual harassment and, second, the strategies to address sexual harassment. We coded four sub-themes regarding participant experiences: (1) their descriptions of the types of harassment, (2) the context of the event, (3) the impact of the harassment, and (4) their preparation to address the harassment. We coded seven sub-themes on strategies used by participants: (1) indirect strategies, (2) confrontation, (3) modifying the clinical encounter, (4) modifying self, (5) alerting others, (6) debrief, and (7) report., Conclusion: Our qualitative study found that sexual harassment of female providers by patients is an ongoing problem, disruptive to the patient-provider relationship, and a possible threat to the well-being of both provider and patient. Formal training on how to address this problem was lacking, but all providers had developed or adapted strategies based on personal experiences or role modeling. Educating providers on strategies is an important next step to addressing this problem.

Background: Sexual harassment and gender-based harassment are common in medicine; however, there is little in the literature regarding men's experience with gender-based and sexual harassment., Objective: The objective of this study was to better understand the experience men have with sexual and gender-based harassment in medicine., Design: We developed and piloted an interview guide based on a review of the literature and conducted semi-structured interviews of male physicians, from trainees to attendings, at a tertiary care facility. Participants were recruited via email between April and August of 2019. These interviews were transcribed verbatim and, using an iterative coding approach based in grounded theory, were coded and analyzed for themes., Main Results: We conducted a total of 16 interviews. Five major themes were identified: (1) personal experiences of harassment, (2) witnessed harassment, (3) characterization of harassment, (4) impact of harassment, and (5) strategies for responding to harassment. The men reported experiences with sexual and gender-based harassment but were hesitant to define these encounters as such. They had minimal emotional distress from these encounters but worried about their professional reputation and lacked training for how to respond to these encounters. Many had also witnessed their female colleagues being harassed by both male patients and colleagues but did not respond to or stop the harassment when it originated from a colleague., Conclusion: We found that men experience sexual harassment differently from women. Most notably, men report less emotional distress from these encounters and often do not define these events as harassment. However, similar to women, men feel unprepared to respond to episodes of harassment against themselves or others. Whether to deter sexual harassment against themselves, or, more commonly, against a female colleague, men can gain the tools to speak up and be part of the solution to sexual harassment in medicine.

Background: To ensure a next generation of female leaders in academia, we need to understand challenges they face and factors that enable fellowship-prepared women to thrive. We surveyed woman graduates of the Robert Wood Johnson Clinical Scholars Program (CSP) from 1976 to 2011 regarding their experiences, insights, and advice to women entering the field., Methods: We surveyed every CSP woman graduate through 2012 (n = 360) by email and post. The survey, 12 prompts requiring open text responses, explored current work situation, personal definitions of success, job negotiations, career regrets, feelings about work, and advice for others. Four independent reviewers read overlapping subsets of the de-identified data, iteratively created coding categories, and defined and refined emergent themes., Results: Of the 360 cohort, 108 (30%) responded. The mean age of respondents was 45 (range 32 to 65), 85% are partnered, and 87% have children (average number of children 2.15, range 1 to 5). We identified 11 major code categories and conducted a thematic analysis. Factors common to very satisfied respondents include personally meaningful work, schedule flexibility, spousal support, and collaborative team research. Managing professional-personal balance depended on career stage, clinical specialty, and children's age. Unique to women who completed the CSP prior to 1995 were descriptions of "atypical" paths with career transitions motivated by discord between work and personal ambitions and the emphasis on the importance of maintaining relevance and remaining open to opportunities in later life., Conclusions: Women CSP graduates who stayed in academic medicine are proud to have pursued meaningful work despite challenges and uncertain futures. They thrived by remaining flexible and managing change while remaining true to their values. We likely captured the voices of long-term survivors in academic medicine. Although transferability of these findings is uncertain, these voices add to the national discussion about retaining clinical researchers and keeping women academics productive and engaged.

Background: Posthospital syndrome is associated with a decrease in physical and cognitive function and can contribute to overall patient decline. We can speculate on contributors to this decline (eg, poor sleep and nutrition), but other factors may also contribute. This study seeks to explain how patients experience hospitalization with particular attention on what makes the hospital stay difficult., Design: Qualitative interview study using grounded theory methodology., Setting: Single-site academic medical center., Patients: Hospitalized general medicine patients., Measurements: Interviews using a semistructured interview guide., Results: We recruited 20 general medicine inpatients from an academic medical center. Of the participants, 12 were women and the mean age was 55 years (range = 22-82 years). We found 4 major themes contributing to the hospital experience: (1) hospital environment (eg, food quality and entertainment), (2) patient factors (eg, indifference and expectations), (3) hospital personnel (eg, care team size and level of helpfulness), and (4) patient feelings (eg, level of control and feeling like an object). We discovered that these emotions arising from hospital experiences, together with the other 3 major themes, led to the patients' perception of their hospital experience overall. We also explore the role that patient tolerance may play in the reporting of patient satisfaction., Conclusions: This article demonstrates the factors affecting how patients experience hospitalization. It provides insight into possible contributors to posthospital syndrome and offers a blueprint for specific quality improvement initiatives. Lastly, it briefly explores how patient tolerance may prove a challenge to the current system of quality reporting., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Objective: The aim of the study was to determine how frequently mental status and mental status changes are documented in the written patient summary ("sign-out") provided to covering physicians., Patients and Methods: This was a retrospective cohort study of general medical patients hospitalized between March 16, 2009, and March 15, 2010, conducted at 2 teaching hospitals. Participants included patients with mental status change adverse events (MSAEs) and their providers. Chart review was performed to identify patients with MSAEs and details about these events. Sign-outs were reviewed for documentation of mental status. Main outcome measures were (1) proportion of patients with MSAEs who had mental status ever recorded in sign-out entries and (2) the proportion of patients with MSAEs whose change in mental status was recorded in the sign-out., Results: Sixty-eight patients had MSAEs and were included in the sample. Fifty percent of MSAEs were attributed to medications; 75% of these events were first detected by nurses. Only 25% of patients with MSAEs had their change in mental status recorded in sign-outs., Conclusions: Recording mental status in written sign-outs is uncommon. Particularly concerning is that patients with MSAEs identified by chart review seldom had sign-outs that reflected those events. Interventions should be designed to increase the recording of this information in sign-outs.

Problem: Medical errors are a health burden. Residents must be aware of patient safety threats and have confidence reporting concerns. Creative modalities for teaching such content (eg, simulation) are resource intensive, while lectures do not assimilate clinical practice. Therefore, the objective of this project was to assess the use of a comic book to train Internal Medicine residents to identify patient safety issues. We report acceptability of the teaching tool and awareness and confidence in identifying patient safety issues using a comic book., Approach: Residents from the Medical College of Wisconsin participated in a 1-hour session to identify 24 safety topics in a comic book. The primary outcomes were awareness and confidence. Engagement and enjoyment were also measured as forms of acceptability of the tool. Comparisons were made using Fisher's exact tests and paired t-tests for awareness questions and Fisher's exact tests for confidence questions. Analyses were performed using SAS V.9.4., Outcomes: Fifty participants were included in the analyses. Proportions in each awareness category were significantly different on post-test in 21 of 24 topics included. The confidence in both identifying safety topics (55.1% precourse to 96% postcourse) and reporting them (35.42%-90%) increased significantly after the curriculum. 90% found the tool enjoyable and 98% found the tool engaging., Next Steps: This curriculum was successful in increasing resident awareness and confidence regarding patient safety. The use of a comic book was acceptable to residents. Future directions include digital conversion of the curriculum and expansion to include multiple settings within the hospital., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background . Communication in the breast cancer treatment consultation is complex. Language barriers may increase the challenge of achieving patient-centered communication and effective shared decision making. Design . We conducted a prospective cohort study among Spanish- and English-speaking women with stage 0 to 3 breast cancer in two urban medical centers in the Midwestern United States. Patient centeredness of care and decisional conflict were compared between Spanish- and English-speaking participants using the Interpersonal Processes of Care (IPC) and Decision Conflict Scale (DCS), respectively. Clinician behaviors of shared decision making were assessed from consultation audio-recordings using the 12-item Observing Patient Involvement in Decision Making (OPTION) scale. Multivariate regression analyses were conducted to control for differences in baseline characteristics and clinician specialty. Results . Fifteen Spanish-speaking and 35 English-speaking patients were enrolled in the study. IPC scores (median, interquartile range [IQR]) were higher (less patient centered) in Spanish- versus English-speaking participants in the domains of lack of clarity (2.5, 1-3 v. 1.5, 1-2), P = 0.028; perceived discrimination (1.1, 1-1 v. 1.0, 1-1), P = 0.047; and disrespectful office staff (1.25, 1-2 v. 1.0, 1-1), P < 0.0005 (Wilcoxon rank-sum test). OPTION scores (median, IQR) were lower in Spanish- versus English-speaking participants (21.9, 17.7-27.1 v. 31.3, 26.6-39.6), P = 0.001 (Wilcoxon rank-sum test). In multivariate analysis, statistically significant differences persisted in the IPC lack of clari ty and disrespectful office staff between Spanish- and English-speaking groups. Conclusions . Our findings highlight challenges in cancer communication for Spanish-speaking patients, particularly with respect to perceived patient centeredness of communication. Further cross-cultural studies are needed to ensure effective communication and shared decision making in the cancer consultation., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)