Discusión de casos en equipos como estrategia para ejercitar el razonamiento clínico desde el ciclo básico / Case discussion in teams as a strategy for practicing clinical reasoning since the basic cycle

Las estrategias curriculares que persiguen la integración entre las ciencias básicas y las ciencias clínicas se enriquecen con la introducción de las discusiones de casos desde los primeros años de la carrera de medicina. En este sentido, este trabajo tuvo el objetivo de reflexionar sobre el valor educacional de una propuesta de ambiente de aprendizaje mediante el método de discusión colectiva de los casos clínicos para los estudiantes de los primeros años de la carrera. Al soporte teórico del trabajo se adicionó un ejemplo de caso adaptado para estudiantes que cursan el ciclo básico de la carrera de medicina. Los métodos activos de aprendizaje desplazan el protagonismo al educando; el entregar y el recibir han sido sustituidos por crear juntos. Subdividir la clase en pequeños grupos (equipos), facilitados por un docente, estimula la interacción estudiantil. El caso clínico sitúa al paciente en el centro del proceso, y la dirección de la discusión se negocia a través del análisis de las pistas que la situación ofrece, desde las diversas interpretaciones de los participantes, ayudados por el profesor. Esta reflexión no pretende sustituir otros escenarios necesarios para comprender el contenido de las disciplinas individuales, porque ese, al ser el primer nivel de conocimiento, necesita reactivarse y analizarse durante la discusión de los casos. La evocación de tópicos en casos clínicos diversos, y la elaboración en el equipo, se espera faciliten la penetración en su esencia (abstracción) y en consecuencia su aplicación en nuevos pacientes(AU)

The curricular strategies that pursue integration between basic sciences and clinical sciences are enriched with the introduction of case discussions from the first academic years of the medical major. In this respect, this work had the objective of reflecting on the educational value of a proposal of a learning setting, through the method of collective discussion of clinical cases for students in the first academic years of the major. The theoretical foundations of the work were added a case example adapted for students at the basic cycle of Medicine. Active learning methods shift prominence to the learner; giving and receiving have been replaced by creating together. Subdividing the class into small groups (teams), facilitated by a teacher, stimulates student interaction. The clinical case places the patient at the center of the process, while the direction of the discussion is negotiated through the analysis of the clues offered by the situation, from the different interpretations of the participants, helped by the teacher. This reflection is not aimed at substituting other settings necessary to understand the content of individual disciplines, because that one, as long as it is the first level of knowledge, needs to be reactivated and analyzed during the case discussions. The evocation of topics through various clinical cases, and team creation, are expected to facilitate the penetration in its essence (abstraction) and consequently its application in new patients(AU)

Exploring Practices of Bedside Shift Report and Hourly Rounding. Is There an Impact on Patient Falls?

OBJECTIVE: To describe the relationship of inpatient falls to bedside shift report (BSR) and hourly rounding (HR). BACKGROUND: Falls are a major healthcare concern. Although measures such as BSR and HR are reported to reduce falls, studies are often based on self-reported data related to nurse compliance with protocols for HR and bedside report. METHODS: Observational data were collected on nursing tasks, including BSR and HR. RESULTS: Nine thousand six hundred ninety-three observations were recorded on 11 units at 4 hospitals over 281 shifts. Falls were associated with shift and day of the week but not BSR, HR, or the frequency of encounters with the patient. The regression model included frequency with patient, shift, day of week, and HR. CONCLUSIONS: Increased nurse frequency with patient may signal increased fall risks. Bedside shift report and HR may require robust and sustained interventions to provide lasting effects.

The impact of residents sitting at the bedside on patient satisfaction during team rounds.

OBJECTIVES: Patient satisfaction ratings are a priority for academic medical centers. Sitting during patient encounters has been recommended as a "best practice."1 A prior study showed that hospitalists had higher-rated communication skills when sitting compared to standing at the bedside during rounds.2 It is unclear whether the same is true of resident-led team rounds. METHODS: We performed a cluster-randomized crossover trial assigning 18 internal medicine residents to sit or stand at the bedside during rounds. RESULTS: A total of 347 patients were surveyed to assess physician communication skills. Standing residents received higher ratings than sitting residents on 2 of 5 survey items and rounding duration did not differ. These results differ from prior work that suggests sitting is superior to standing2-6. CONCLUSION: We suspect that one rounding member sitting, while all others stand, is not enough to impact patients' perceptions. These results suggest that initiatives to optimize patient satisfaction on resident-staffed units should be focused elsewhere. PRACTICE IMPLICATIONS: Patients do not have better impressions of physician communication skills when one team member is sitting and the rest are standing.

Evaluation of a sepsis teaching rounds simulation for pharmacy students.

BACKGROUND AND PURPOSE: The goal of this prospective, observational cohort study was to determine if simulated interdisciplinary teaching rounds improved student perceptions of confidence and attitudes towards working as part of a team. The secondary objective of this study was to investigate changes in student knowledge of the management of sepsis. EDUCATIONAL ACTIVITY AND SETTING: Students participated in a traditional sepsis lecture followed by a simulated interdisciplinary rounding experience. Confidence and collaborative attitudes were assessed using a 5-point Likert scale (1=strongly disagree, 5=strongly agree). Changes in knowledge were measured using multiple choice questions. Students completed these tools at three points in time: pre-lecture, post-lecture, and post-simulation. FINDINGS: Student confidence and attitudes related to interdisciplinary rounds improved following the simulation (2 of 4 items, p=0.003; 2 of 5 items, p<0.05). Also, most students agreed or strongly-agreed that the simulation reinforced knowledge gained from lecture (94.7%), that lecture followed by a simulation was the most effective way to learn about sepsis (94.7%), and that the simulation helped reinforce critical-thinking skills (94.7%). Knowledge improved between the didactic lecture and the simulation, but these differences were not found to be statistically significant. SUMMARY: A simulated interdisciplinary rounding experience may increase student confidence during teaching rounds and improve attitudes towards working alongside other healthcare professionals. Incorporating rounding simulations into pharmacy curricula may be beneficial towards student success on rounds.

Changing nursing practice: Implementation challenges of intentional rounding on three rehabilitation units.

The purpose of this article is to critically examine the process and results of a participatory action study designed to implement intentional rounding on a rehabilitation inpatient service. As a change initiative, this brief case study highlights the successes and challenges of implementing a practice intervention. Intentional rounding is a nursing intervention whereby hourly contact and support is provided to patients and families to strengthen the therapeutic relationship and proactively address their needs. Three units implemented rounding, and pre- and post-data were collected on four indicators: patient falls, call bell frequencies, satisfaction with care, and the nurses' practice environment. The results demonstrated small, positive changes in all indicators, but the level of rounding was lower than expected. Focus groups revealed the complexities of integrating rounding into established routines. Three factors were identified that contributed to the findings.

Morning report innovation: Case Oriented Report and Exam Skills.

Morning report is a valuable educational conference but is often a stand-alone classroom-based discussion which misses the opportunity for bedside education. In this report, we describe an innovative morning report structure - the Case Oriented Report and Exam Skills (CORES) - that addresses this pitfall of the traditional case conference format and brings learners to the bedside. The key components of CORES include highlighting concepts of clinical reasoning, emphasizing evidence-based and hypothesis-driven physical exam (HDPE), and integrating emerging bedside technologies such as point-of-care ultrasound (POCUS).

Project More Doctors for Brazil in remote areas of the state of Roraima: relationship between doctors and the Special Supervision Group / Projeto Mais Médicos para o Brasil em áreas remotas de Roraima, Brasil: relações entre médicos e Grupo Especial de Supervisão / Proyecto Más Médicos para Brasil en áreas remotas de Roraima, Brasil: relaciones entre los médicos y el Grupo Especial de Supervisión

ABSTRACT This article aims at discussing aspects of the Project More Doctors for Brazil's Special Supervision Group in areas of difficult access in the Brazilian state of Roraima. It is focused on the relationships between supervisors and doctors, identifying potentialities and difficulties, and highlighting strategies to overcome them. This is an experience report from a thematic content analysis of documents produced by supervisors in 2015 and 2016. Three key categories emerged: potentialities, challenges of the process and constructions based on supervision. Based on the analysis, this is an innovative relationship in healthcare, where academia and services hardly ever come together. It is a complex relationship with structural, cultural and educational limitations. It requires creativity and planning to play all different roles under construction.

RESUMO O artigo busca discutir aspectos da experiência de atuação do Grupo Especial de Supervisão do Projeto Mais Médicos para o Brasil (PMMB) em áreas de difícil acesso no estado de Roraima, Brasil, com foco nas relações entre supervisores e médicos, identificando potencialidades e dificuldades e destacando estratégias utilizadas para superá-las. Trata-se de um relato de experiência oriundo de uma análise de conteúdo temática de documentos produzidos pelos supervisores nos anos de 2015 e 2016, com o surgimento de três categorias-chave: potencialidades, desafios do processo e construções a partir da supervisão. Na análise, percebeu-se que essa relação se apresenta como inovadora, em um espaço de cuidado em saúde no qual dificilmente há aproximação entre academia e serviço, revelando-se complexa, com limites estruturais, culturais e de formação, necessitando de inventividade e planejamento para que cumpra sua variedade de papéis em construção.

Resumen El objetivo del artículo es discutir aspectos de la experiencia de actuación del Grupo Especial de Supervisión del Proyecto Más Médicos para Brasil en áreas de difícil acceso en el Estado de Roraima, Brasil, enfocándose en las relaciones entre supervisores y médicos, identificando potencialidades, dificultades y subrayando las estrategias utilizadas para superarlas. Se trata de un relato de experiencia proveniente de un análisis de contenido temático de documentos producidos por los supervisores en los años 2015 y 2016, con el surgimiento de tres categorías clave: potencialidades, desafíos del proceso y construcciones a partir de la supervisión. En el análisis se percibió que esa relación se presenta como innovadora en un espacio de cuidado de salud en donde difícilmente hay aproximación entre academia y servicio, revelándose compleja, con límites estructurales, culturales y de formación, necesitando capacidad de invención y planificación para que cumpla su variedad de papeles en construcción.

Training in Cardiovascular Epidemiology and Prevention: A 50-Year Journey From Makarska to Goa.

The first International Ten-Day Teaching Seminar on Cardiovascular Epidemiology and Prevention was held in Makarska, in the former Yugoslavia in August 1968. The goals of the Seminar were to help bridge the gap between cardiology and cardiovascular epidemiology, promote international collaboration, and provide training in cardiovascular epidemiology and prevention. The 50th Seminar took place in Goa, India in June 2018. This perspective article provides an overview of the major accomplishments of the Seminar as well as its persisting challenges. It also addresses unique opportunities as the Seminar embarks on the next phase of international training seminars in cardiovascular epidemiology and prevention. In particular, this article highlights strategies that offer the opportunity to significantly increase the number of Seminar participants annually, especially from low- and middle-income countries and Small Island Developing States where the burden and trend in cardiovascular diseases and cardiometabolic risk factors pose the greatest concerns. It also discusses the importance of using big data for descriptive, predictive, and prescriptive analytics at the local level, and the need to leverage information technology and digital platforms to create greater access to and sharing of lessons learned. The article also highlights the opportunity to embrace active dissemination and implementation research and the science of health care delivery as important components of training in cardiovascular disease epidemiology and prevention.

Improving Pediatric Resident Communication During Family-Centered Rounds Using a Novel Simulation-Based Curriculum.

Introduction: While family-centered rounds (FCR) have become increasingly important in pediatrics, there is often no training for residents on appropriate FCR practice. This curriculum was developed to address this identified gap in pediatric trainee education through a combination of didactic presentation, direct observation, and simulated FCR. Methods: Residents participated in a didactic presentation on key components of FCR and tenets of communication with families. A subset of residents participated in a simulated intervention in which they practiced an FCR encounter using a mock patient case and received immediate feedback from a multidisciplinary team. Following the simulation, residents completed follow-up surveys and focus group discussions to assess their experience and comfort. Resident trainees were observed and rated during FCR by trained parent advisors using a novel FCR checklist both before and after participation in the simulation. Results: This curriculum was implemented with 10 pediatric interns (intervention group). These residents demonstrated statistically significant improvements in the areas of greeting family by name and soliciting rounding preferences, enhancing family comfort in participating in FCR, and increasing family engagement in FCR. Compared to controls, intervention group residents had higher ratings on the majority of performance items. Resident-reported self-efficacy in conducting FCR increased following the intervention, and the feedback portion of the intervention was highly valued. Discussion: Simulation-based training is an effective model for teaching residents best practices in FCR with lasting impact on resident communication skills as seen in comparative analysis from before and after the intervention.

Professional and political reflections on the 'grand round': a critical case study.

This case study presents a critical reflective account of a change to working practices in one NHS Trust. To promote quality care and effective clinical decision making, a 'grand round' was introduced in the orthopaedic department. Implementation presented frustrations and challenges for members of the multidisciplinary team. These are explored using transformative learning and critical reflection, enabling connections to be made between micro-level interactions of clinical care and macro-level structures that frame healthcare services. It is important that nurses recognise the escalating impact of a neoliberal agenda, and new public management, that drive UK health policy and politics. The value base of nursing is threatened by a corporate culture that measures performance in terms of institutional targets rather than individual care.

The Impact of Bedside Interdisciplinary Rounds on Length of Stay and Complications.

BACKGROUND: Communication among team members within hospitals is typically fragmented. Bedside interdisciplinary rounds (IDR) have the potential to improve communication and outcomes through enhanced structure and patient engagement. OBJECTIVE: To decrease length of stay (LOS) and complications through the transformation of daily IDR to a bedside model. DESIGN: Controlled trial. SETTING: 2 geographic areas of a medical unit using a clinical microsystem structure. PATIENTS: 2005 hospitalizations over a 12-month period. INTERVENTIONS: A bedside model (mobile interdisciplinary care rounds [MICRO]) was developed. MICRO featured a defined structure, scripting, patient engagement, and a patient safety checklist. MEASUREMENTS: The primary outcomes were clinical deterioration (composite of death, transfer to a higher level of care, or development of a hospital-acquired complication) and length of stay (LOS). Patient safety culture and perceptions of bedside interdisciplinary rounding were assessed pre- and postimplementation.. RESULTS: There was no difference in LOS (6.6 vs 7.0 days, P = 0.17, for the MICRO and control groups, respectively) or clinical deterioration (7.7% vs 9.3%, P = 0.46). LOS was reduced for patients transferred to the study unit (10.4 vs 14.0 days, P = 0.02, for the MICRO and control groups, respectively). Nurses and hospitalists gave significantly higher scores for patient safety climate and the efficiency of rounds after implementation of the MICRO model. LIMITATIONS: The trial was performed at a single hospital. CONCLUSIONS: Bedside IDR did not reduce overall LOS or clinical deterioration. Future studies should examine whether comprehensive transformation of medical units, including co-leadership, geographic cohorting of teams, and bedside interdisciplinary rounding, improves clinical outcomes compared to units without these features. Journal of Hospital Medicine 2017;12:137-142.

Returning to the Bedside: Notes From a Clinical Educator.

Over the past 3 decades, teaching rounds have drifted away from the bedside in favor of management discussions in a conference room or hallway. As a result, patients and families--2 of the most valuable resources in health care--are being left out of the loop. This trend is now being reversed by bedside presentations of newly admitted patients and structured interdisciplinary bedside rounds.

Requiem for the grand round.

The time-honoured tradition of Grand Round is firmly rooted in medical education, but has little evidence for its effectiveness or its impact on patient management. A mode of didactic teaching, Grand Round has lost its appeal in modern medical education with dwindling attendance at Grand Rounds worldwide. Once a platform for eminence-based medicine and a cross fertilisation of medical ideas, emphasis on sub-specialisation and clinical governance, combined with rota, trainee engagement and attendance failures has made Grand Round obsolete. To survive, Grand Round must have evidence for its effectiveness in medical education. It must be able to compete with other forms of teaching and adapt by using technology to reach trainees. Engaging the audience and encouraging participation needs to be woven into the fabric of the modern Grand Round, alongside learning clinical skills and developing clinical reasoning. Understanding the needs of today's trainees and their involvement in formulating the Grand Round programme is vital. Attendance at Grand Round is a recognised measure of its success and will be used in its evaluation. Questions still remain regarding the future of Grand Round. Its survival will depend upon its ability to change with time and reclaim its place as a credible tool to promote learning.