Internal medicine paging curriculum to improve physician-nurse interprofessional communication: a single center pilot study.

Effective physician-nurse communication is critical to patient safety, yet internal medicine trainees are rarely given feedback on this skill. In order to address this gap, we developed a 4-week simulated paging curriculum for senior medical students. Standardized Registered Nurses administered five acute inpatient paging cases to students via telephone and scored communication on a 10-point global scale (1 = highly ineffective to 10 = highly effective) and seven communication domains using a 5-point Likert-type scale. The domains included precision/clarity, instructive, directing, assertive, ability to solicit information, engaged, and structured communication. Students received verbal and written feedback from the nurses on communication skills and clinical decision-making. Our primary goal was to determine if student-nurse communication improved throughout the curriculum. Data were analyzed using multivariate ANOVAs with repeated measures. Twenty-seven students participated. Global communication scores increased significantly from case 1 to case 5 (7.1 to 8.7, p < .01). The following communication domains increased significantly: precision (3.8 to 4.4, p < .01), instructive (3.6 to 4.7, p < .01), directing (4.0 to 4.6, p = .02), assertiveness (4.0 to 4.7, p = .04), engaged (4.1 to 4.7, p < .01). In conclusion, this curriculum can be an innovative approach to improve physician-nurse communication using standardized registered nurses to deliver structured feedback to medical trainees.

Zinc acetate lozenges for treating the common cold: an individual patient data meta-analysis.

AIMS: The aim of this study was to determine whether the allergy status and other characteristics of common cold patients modify the effects of zinc acetate lozenges. METHODS: We had available individual patient data for three randomized placebo-controlled trials in which zinc acetate lozenges were administered to common cold patients. We used both one stage and two stage meta-analysis to estimate the effects of zinc lozenges. RESULTS: The total number of common cold patients was 199, the majority being females. Eighty percent of them fell into the age range 20-50 years. One third of the patients had allergies. The one stage meta-analysis gave an overall estimate of 2.73 days (95% CI 1.8, 3.3 days) shorter colds by zinc acetate lozenge usage. The two stage meta-analysis gave an estimate of 2.94 days (95% CI 2.1, 3.8 days) reduction in common cold duration. These estimates are to be compared with the 7 day average duration of colds in the three trials. The effect of zinc lozenges was not modified by allergy status, smoking, baseline severity of the common cold, age, gender or ethnic group. CONCLUSION: Since the effects of zinc acetate lozenges were consistent between the compared subgroups, the overall estimates for effect seemed applicable over a wide range of common cold patients. While the optimal composition of zinc lozenges and the best frequency of their administration should be further investigated, given the current evidence of efficacy, common cold patients may be encouraged to try zinc lozenges for treating their colds.

Competency-based education: programme design and challenges to implementation.

CONTEXT: Competency-based education (CBE) has been widely cited as an educational framework for medical students and residents, and provides a framework for designing educational programmes that reflect four critical features: a focus on outcomes, an emphasis on abilities, a reduction of emphasis on time-based training, and promotion of learner centredness. Each of these features has implications and potential challenges for implementing CBE. METHODS: As an experiment in CBE programme design and implementation, the University of Michigan Master of Health Professions Education (UM-MHPE) degree programme was examined for lessons to be learned when putting CBE into practice. The UM-MHPE identifies 12 educational competencies and 20 educational entrustable professional activities (EPAs) that serve as the vehicle for both learning and assessment. The programme also defines distinct roles of faculty members as assessors, mentors and subject-matter experts focused on highly individualised learning plans adapted to each learner. CONCLUSIONS: Early experience with implementing the UM-MHPE indicates that EPAs and competencies can provide a viable alternative to traditional courses and a vehicle for rigorous assessment. A high level of individualisation is feasible but carries with it significant costs and makes intentional community building essential. Most significantly, abandoning a time-based framework is a difficult innovation to implement in a university structure that is predicated on time-based education.

Assessment challenges in competency-based education: A case study in health professions education.

There is a growing demand for health sciences faculty with formal training in education. Addressing this need, the University of Michigan Medical School created a Master in Health Professions Education (UM-MHPE). The UM-MHPE is a competency-based education (CBE) program targeting professionals. The program is individualized and adaptive to the learner's situation using personal mentoring. Critical to CBE is an assessment process that accurately and reliably determines a learner's competence in educational domains. The program's assessment method has two principal components: an independent assessment committee and a learner repository. Learners submit evidence of competence that is evaluated by three independent assessors. The assessments are presented to an Assessment Committee who determines whether the submission provides evidence of competence. The learner receives feedback on the submission and, if needed, the actions needed to reach competency. During the program's first year, six learners presented 10 submissions for review. Assessing learners in a competency-based program has created challenges; setting standards that are not readily quantifiable is difficult. However, we argue it is a more genuine form of assessment and that this process could be adapted for use within most competency-based formats. While our approach is demanding, we document practical learning outcomes that assess competence.

Medical school handoff education improves postgraduate trainee performance and confidence.

OBJECTIVES: Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training. METHODS: About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p<0.05. RESULTS: About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p<0.05); they were also more confident in their handoff abilities (p<0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p<0.05). CONCLUSIONS: This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.

How medical students' trauma histories affect their clinical clerkship experiences.

BACKGROUND: As the gender demographics of medical students have evolved over the past decades, it is important to understand potential stressors and challenges that may affect clinical learning experiences. This study investigated the prevalence of prior sexual assault (SA) and interpersonal violence (IPV) in medical students and how these affect their clinical clerkship experiences. METHODS: A survey was distributed to third- and fourth-year medical students at a single institution in August 2022 querying respondents on demographics and prior experiences with SA/IPV at any point in their lives. Respondents who indicated they had previously experienced SA/IPV were directed to questions about how these experiences affected clerkships. FINDINGS: Of 419 students, 125 responded to the survey (30.8% response rate). Forty (31.1%) reported a history of SA/IPV-32 (80.0%) women, five (12.5%) men, and three (7.5%) who did not report gender or identified as non-binary. Of the 40 respondents with a history of SA/IPV, 20 (50.0%) reported that their prior history affected their overall clinical experience, and nine (22.5%) felt that it affected their performance. Only seven (17.5%) reported using any resources, such as counselling, during their clerkships. Narrative responses discussed significant effects on performing physical exams, taking a history, interacting with team members, and engaging during clerkships. DISCUSSION: This work demonstrates the high number of students affected by SA/IPV and how these prior experiences affected core components of their clerkship experiences. CONCLUSIONS: Institutions must be proactive to create better supports for learners with histories of trauma, including SA/IPV.

Internal medicine house officers' attitudes and experience with patients who overstep patient-physician boundaries.

Maintenance of appropriate social boundaries is an essential aspect of patient care. Given limited clinical experience, house officers may be especially vulnerable to such transgressions. We studied the frequency of patients' transgressions of boundaries and house officer responses to these transgressions. An online survey was administered to internal medicine house officers at the University of Michigan Health System that addressed the frequency of patient-physician boundary transgressions, house officer responses to transgressions, and the perceived need for education regarding transgressions. The frequency of reported patient transgressions of various boundaries during the past 6 months ranged from 0 to more than 30. The most common reported incident was being called by their first name, and the least common incidents included patients engaging/attempting to engage in sexual contact and attempting to give expensive gifts. Most respondents denied the need for education regarding appropriate boundaries with patients; however, most perceived a need for training on how to respond to transgressions. Overall, there was a wide range in reported frequencies of transgressions. The frequency of transgressions reported by house officers was greater than what is previously described for attending physicians though their responses to transgressions were similar.

"Patient's Family Wants an Update": A Curriculum for Senior Medical Students to Deliver Telephone Updates for Hospitalized Patients.

Introduction: Residents have the important task of updating family members of hospitalized patients, often by telephone. There are limited curricula dedicated to preparing medical students for this task, which will become their responsibility as residents. Methods: We created a virtual workshop, including four patient cases, to facilitate teaching senior medical students enrolled in an internal medicine residency preparation course. Students alternated role-playing either physician or family member. We assessed performance using a self-assessment rubric before (preworkshop) and after (postworkshop) a didactic session. We compared pre- and postworkshop scores using t tests. We also used a retrospective pre-post survey with a 5-point Likert scale to assess each participant's comfort level, knowledge, and perceived ability. Results: Thirty-nine students completed the pre- and postworkshop evaluation (response rate: 70%). The mean score on the preworkshop self-assessment was 83% (SD = 9%) and on the postworkshop self-assessment was 94% (SD = 8%; p < .01), with a large effect size of 1.22. Among the 31 students (62%) who completed the survey, there was improvement in comfort level (2.9 vs. 3.7, p < .001), knowledge (2.7 vs. 3.8, p < .001), and perceived ability (2.9 vs. 3.7, p < .001). Discussion: Our workshop was effective in teaching medical students a structured format for providing telephone updates and was well received. The workshop was also effective when delivered virtually (with videos off) to mimic the non-face-to-face communication that occurs when delivering family updates by telephone. The curriculum could be expanded to other learner groups.

Conceptual model for reducing infections and antimicrobial resistance in skilled nursing facilities: focusing on residents with indwelling devices.

Infections in skilled nursing facilities (SNFs) are common and result in frequent hospital transfers, functional decline, and death. Colonization with multidrug-resistant organisms (MDROs) - including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacilli (R-GNB) - is also increasingly prevalent in SNFs. Antimicrobial resistance among common bacteria can adversely affect clinical outcomes and increase health care costs. Recognizing a need for action, legislators, policy-makers, and consumer groups are advocating for surveillance cultures to identify asymptomatic patients with MDROs, particularly MRSA in hospitals and SNFs. Implementing this policy for all SNF residents may be costly, impractical, and ineffective. Such a policy may result in a large increase in the number of SNF residents placed in isolation precautions with the potential for reduced attention by health care workers, isolation, and functional decline. Detection of colonization and subsequent attempts to eradicate selected MDROs can also lead to more strains with drug resistance. We propose an alternative strategy that uses a focused multicomponent bundle approach that targets residents at a higher risk of colonization and infection with MDROs, specifically those who have an indwelling device. If this strategy is effective, similar strategies can be studied and implemented for other high-risk groups.

Geriatrics educational outreach: A tale of three GRECCS.

Current geriatrics workforce projections indicate that clinicians who care for adults will need basic geriatrics knowledge and skills to address the geriatric syndromes and issues that limit functional independence and complicate medical management. This is most evident for the clinicians caring for veterans in the Department of Veterans Affairs hospitals and clinics nationwide. Geriatric Research, Education and Clinical Centers (GRECCs), whose staff are geriatric-content experts, have developed a number of programs to tackle this daunting educational task. This article introduces three different programs designed and implemented by GRECCs to train currently practicing health care providers in the Veterans Health Administration medical clinics. It also describes the successes and lessons learned from these three programs.

The Development of a Video Intervention to Improve Senior Medical Students' Performance on Outpatient Telephone Encounters: a Delphi Analysis and Randomized Controlled Trial.

Introduction: Postgraduate trainees address outpatient telephone calls (OTCs) with little prior training. This study determines the skills necessary for OTCs and examines whether a video intervention improves medical students' performance on simulated OTCs. Materials and Methods: We utilized a Delphi technique to determine skills needed for OTCs and created a 9-min video teaching these skills. Senior medical students were randomized to Intervention (viewed video) and Control (did not view video) groups. Students were assessed pre-/post-intervention on simulated OTCs. The primary outcome was the between-group difference in improvement. Results: The Delphi yielded 34 important skills with the highest focus on communication (n = 13) and triage (n = 6). Seventy-two students completed assessments (Control, n = 41; Intervention, n = 31). The score (mean ± SD) improved 4.3% in the Control group (62.3 ± 14.3% to 66.6 ± 25.0%) and 12.2% in the Intervention group (60.7 ± 15.2% to 72.9 ± 20.4%, p = 0.15). The effect size measured by Cohen's d was 0.55, considered effective (> 0.33) for an educational intervention. Conclusions: This project fills a gap in OTC training. The use of the Delphi technique, intervention development based on the results, and evaluation of efficacy is a process that could be reproduced for other educational gaps. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-021-01331-w.

What Does "Patient-Centered" Mean? Qualitative Perspectives from Older Adults and Family Caregivers.

This study aimed to (1) examine what patient-centeredness means for older adults and family caregivers, and (2) assess circumstances underlying their preference for geriatric care. We conducted separate focus groups with older adults and family caregivers of older adults about health care experiences and expectations and conducted a vignette-based experiment to assess preference for geriatric care. Participants expressed a need for greater skill and empathy and integration of caregivers. They preferred geriatric care to usual primary care with increasing social, health, and healthcare complexity. Distinct needs of older adults should be considered in referral practices to geriatric medicine.

Exploring How Personal, Social, and Institutional Characteristics Contribute to Geriatric Medicine Subspecialty Decisions: A Qualitative Study of Trainees' Perceptions.

PURPOSE: To explore internal medicine residents' and geriatrics fellows' perceptions of how personal, social, and institutional characteristics contribute to their professional identity and subspecialty decisions related to geriatric medicine. METHOD: The authors conducted 23 in-depth, semistructured interviews with internal medicine residents, with and without an interest in geriatrics, and geriatrics fellows across 3 academic medical centers in the United States from October 2018 through June 2019. They then used a qualitative narrative approach to analyze the interview data. RESULTS: Trainees related personal experiences, such as exposure to physicians and experiences with grandparents, to their interest in medicine. Trainees with an interest in geriatrics at 2 institutions did not feel supported, or understood, by peers and mentors in their respective institutions but maintained their interest in the field. The following variations between institutions that are supportive and those that are not were noted: the number of geriatricians, the proximity of the institution to geriatrics clinics, and the ways in which institutional leaders portrayed the prestige of geriatric medicine. Institutional characteristics influenced trainees' understanding of what it meant to be a doctor, what meaning they garnered from work as a physician, and their comfort with different types of complexity, such as those presented when providing care to older adults. CONCLUSIONS: Institutional characteristics may be particularly important in shaping trainee interest in geriatric medicine. Institutions should encourage leadership training and opportunities for geriatricians so they can serve as role models and as hands-on mentors for trainees beginning in medical school. Increasing the number of geriatricians requires institutions to increase the value they place on geriatrics to generate a positive interest in this field among trainees. Institutions facilitating formation of professional identity and sense of purpose in work may consider engaging geriatricians in leadership and mentoring roles as well as curriculum development.

Student Perceptions of educational handovers.

BACKGROUND: Educational handovers can provide competency information about graduating medical students to residency program directors post-residency placement. Little is known about students' comfort with this novel communication. OBJECTIVE: To examine graduated medical students' perceptions of educational handovers. METHODS: The authors created and distributed an anonymous survey to 166 medical students at a single institution following graduation in the spring of 2018. Within this cohort, 40 students had an educational handover sent to their future program director. The survey explored comfort level with handovers (1=very uncomfortable; 5=very comfortable) and ideal content (e.g., student strengths, areas for improvement, goals, grades received after residency application). Respondents self-reported their performance in medical school and whether a handover was sent. Correlation analyses examined relationships between performance and other variables. T-tests examined differences between students who did and did not have a handover letter sent. RESULTS: The survey response rate was 40.4% (67/166) - 47.8% of students felt comfortable with handovers, 19.4% were neutral, and 32.8% were uncomfortable. There was no correlation between self-reported medical school performance and comfort level. Respondents felt most strongly that strengths should be included, followed by goals. Those who had a handover letter sent expressed significantly higher comfort level (3.8 ± 1.0 vs. 2.6 ±1.3, p=0.003) with this communication. CONCLUSION: Medical students reported varying levels of comfort with educational handovers; however, those who had handovers sent had more positive perceptions. In order to improve the education continuum, it is essential to engage students in the development of this handover communication.

Eating Problems in Advanced Dementia: Navigating Difficult Conversations.

Introduction: The majority of older adults with advanced dementia (AD) develop difficulties with eating and swallowing, often prompting concerns about nutrition and quality of life. Employing a palliative approach requires providers to attain skills in addressing symptoms and communicating with family caregivers about the trajectory of AD and associated dysphagia, as well as to elicit goals of care. Research suggests internal medicine (IM) residents often perceive minimal education during training addressing skills needed to care for patients with AD. Methods: We developed and piloted a small-group interactive seminar utilizing a trigger video depicting a family meeting addressing eating problems in a patient with AD. Case-based learning, small-group discussion, and learner reflection were employed. We assessed the impact on 82 of the 106 IM, medicine-pediatrics, and neurology residents who participated in the seminar. Results: Participant evaluation indicated residents showed high satisfaction and perceived the educational content of the seminar to be robust and clinically relevant. We found statistically significant (p < .001) improvements in self-reported confidence in dementia-specific skills postseminar. Effect size was large to very large (Cohen's d = 1.3-1.7). Discussion: An interactive, case-based seminar utilizing a video depicting a realistic family meeting improved residents' self-efficacy in skills needed to address nutritional issues, engage in goals-of-care discussions, and reflect on concerns among caregivers of patients with AD. The seminar teaches important geriatric and palliative concepts meant to improve residents' ability to care for older adults with AD in their future careers.

Perceptions and attitudes are primary contributors to insulin delivery system satisfaction in people with type 2 diabetes.

BACKGROUND: This study identifies factors that influence satisfaction with an insulin delivery system (IDS). Knowledge of such factors could help identify individuals who would benefit from innovative IDS. METHODS: Individuals with type 2 diabetes who use insulin, recruited from a general and chronic illness panel, participated in a web-based survey that included questions about demographics, self-reported diagnoses and hemoglobin A1c (HbA1c), current IDS used, insulin therapy attitudes, current IDS features, and satisfaction with IDS. Univariate analyses identified variables associated with IDS satisfaction (P < 0.05); those variables were entered into stepwise linear regression analyses with IDS satisfaction as the dependent variable. RESULTS: Six hundred sixty-seven individuals with type 2 diabetes participated (mean age, 57 years; 52% female; 88% Caucasian; 73% vial/syringe users, 27% insulin pen users). IDS satisfaction was associated (P < 0.05) with gender, health status, HbA1c, self-reported comorbidity, insulin therapy attitudes, IDS type, and evaluation of IDS features. Among individuals who reported their HbA1c (n = 438), the best predictors of IDS satisfaction were perceived effectiveness and value of insulin therapy, evaluation of IDS activity interference, and commitment to insulin therapy (R2 = 0.49, P < 0.001). Among all participants (n = 667), a second regression analysis that employed a variable representing report of HbA1c found the best predictors of IDS satisfaction included those in the first analysis with the addition of gender, report of HbA1c, and evaluation of IDS ease of use. These variables provided additional variance (R2 = 0.56, P < 0.001). CONCLUSIONS: In people with type 2 diabetes, positive perceptions and attitudes about insulin therapy have greater influence than the type of IDS used on IDS satisfaction.

Are medical students trained in cross-cover?

OBJECTIVES: To examine the current state of cross-cover education in undergraduate medical education and intern perceived readiness to provide cross-cover. METHODS: An electronic survey was distributed to 126 incoming interns in surgery, internal medicine, family medicine and paediatrics residencies at a single academic centre. Information regarding prior cross-cover training, experience, confidence, and responses to a sample cross-cover case were obtained. RESULTS: The survey response rate was 69.8% (88 of 126), which included both partial and complete responses. Fifty-seven interns out of 85 (67.1%) had no formal training and 51 (60.0%) had no experience performing cross-cover. They reported feeling unprepared to provide cross-cover, with an average score of 1.8 on a 5-point Likert scale (1, not at all confident; 5, extremely confident). Interns had more confidence in performing cross-cover tasks if they had prior direct cross-cover experience (p = 0.001), and were the least confident in performing the initial evaluation and management of urgent issues (Likert score = 1.6). Scores on the sample case were correlated with the amount of prior experience with patients (p = 0.06). Only 77.7% of interns indicated that they would notify their senior resident in two urgent scenarios. Those who reported higher confidence in knowing when to ask for help were more likely to appropriately notify their senior colleague (p = 0.005). We identified gaps in cross-cover training and in the preparedness of incoming interns CONCLUSIONS: We identified gaps in cross-cover training and in the preparedness of incoming interns. This has important implications for the first day of residency, when interns are often asked to perform cross-coverage, yet feel unprepared to do so and express the greatest concern in urgent cross-cover scenarios. Addressing this curricular gap is crucial in assuring safe cross-cover care.

Inpatient Cross-Cover Consensus Recommendations for Medical and Surgical Residents: A Delphi Analysis.

BACKGROUND: Residents regularly care for hospitalized patients for whom they are not the primary provider (cross-cover), often without guidance. OBJECTIVE: We identified and defined components of safe cross-cover care. METHODS: Sixty medical and surgical faculty physicians and chief residents from the Midwest were invited to participate in a Delphi study analyzing the appropriateness of cross-covering residents evaluating patients at bedside, deferring issues to the primary team, documenting a note, contacting the attending, and communicating with nurses. The first survey was free text, and responses were categorized. In the second survey, physicians rated categorized responses based on appropriateness using a 5-point Likert scale. High consensus was defined as ≥ 80% agreement, approaching consensus as 51% to 79% agreement, and nonconsensus as ≤ 50% agreement. Results were analyzed by specialty and cross-cover experience in the past year using Pearson χ2 test or Fisher exact test. RESULTS: Forty respondents (67%) completed the first survey and 30 (50%) completed the second. Responses led to 46 categories. Twenty-eight items (60%) achieved high consensus, 8 (17%) approached consensus, and 10 (22%) did not achieve consensus, with no difference based on specialty or experience. Responses with 100% consensus included: residents should evaluate a patient at bedside whenever asked by the nurse; documentation should occur for change in level of care, death, code, or rapid response team activation; and physician-nurse communication should be respectful and closed loop. CONCLUSIONS: This regional physician panel reached consensus on 28 elements important in cross-cover care, which can be used for training and future studies.

Does Performance on Evidence-Based Medicine and Urgent Clinical Scenarios Assessments Deteriorate During the Fourth Year of Medical School? Findings From One Institution.

PURPOSE: The fourth year of medical school (M4) should prepare students for residency yet remains generally unstructured, with ill-defined goals. The primary aim of this study was to determine whether there were performance changes in evidence-based medicine (EBM) and urgent clinical scenarios (UCS) assessments before and after M4 year. METHOD: University of Michigan Medical School graduates who matched into internship at Michigan Medicine completed identical assessments on EBM and UCS at the beginning of M4 year and 13 months later during postgraduate year 1 (PGY1) orientation. Individual scores on these assessments were compared using paired t test analysis. The associations of academic performance, residency specialty classification, and initial performance on knowledge changes were analyzed. RESULTS: During academic years 2014 and 2015, 76 students matched into a Michigan Medicine internship; 52 completed identical EBM stations and 53 completed UCS stations. Learners' performance on the EBM assessment decreased from M4 to PGY1 (mean 93% [SD = 7%] vs. mean 80% [SD = 13%], P < .01), while performance on UCS remained stable (mean 80% [SD = 9%] vs. mean 82% [SD = 8%], P = .22). High M4 performers experienced a greater rate of decline in knowledge level compared with low M4 performers for EBM (-20% vs. -4%, P = .01). Residency specialty and academic performance did not affect performance. CONCLUSIONS: This study demonstrated degradation of performance in EBM during the fourth year and adds to the growing literature that highlights the need for curricular reform during this year.