"Many people know nothing about us": narrative medicine applications at a student-run free clinic.

Narrative medicine is an approach to healthcare that acknowledges the stories of patients' lives both within and beyond the clinical setting. Narrative medicine has been increasingly recognized as a promising tool to support modern educational needs in health professions training, such as interprofessional practice, while enhancing quality of care. Here, we describe the development, implementation, and application of a narrative medicine program at the University of Minnesota Phillips Neighborhood Clinic. First, in a qualitative analysis of patient stories (n = 12) we identified themes regarding the value of the storytelling experience; patients' personal journeys; and patients' experiences in healthcare and other systems. Second, an interprofessional educational activity for student volunteers (n = 57) leveraging a patient narrative was observed to be satisfactory, significantly improve attitudes toward the underserved, and enhance quality of care from the perspectives of trainees. Together, findings from the two studies imply the potential benefits of broader incorporation of narrative medicine into interprofessional service settings, for both learners and patients.

Development and validation of a tool to assess the readiness of a clinical teaching site for interprofessional education (InSITE).

Interprofessional education within clinical teaching sites is a key part of training for pre-professional students. However, the necessary characteristics of these interprofessional clinical teaching sites is unclear. We developed a tool, the Interprofessional Education Site Readiness, or InSITE, tool, for individuals at a site to use as a self-assessment of the site's current readiness for providing interprofessional education. The tool progressed through six stages of development, collecting evidence for validity and reliability, resulting in a final tool with 23 questions distributed across five domains. Data from 94 respondents from a variety of national sites were used for the item analysis showing acceptable item-to-total correlations. Internal reliability testing gave a Cronbach's coefficient alpha of more than 0.70 for each group level comparison. Known groups validity testing provides strong evidence for its responsiveness in detecting differences in sites where IPE is implemented. The results of the testing lead us to conclude that the InSITE tool has acceptable psychometric properties. Additionally, we discovered that the process in which the InSITE tool was used demonstrated that it can facilitate learning in practice for the health professionals and can help make implicit, informal workplace learning and the hidden curriculum explicit.

Escaping the professional silo: an escape room implemented in an interprofessional education curriculum.

Communication skills among healthcare professionals are a necessary component in ensuring quality outcomes for patients. This report describes the design and curricular implementation of an interprofessional escape room, an innovative way to promote communication and positive team dynamics among students. In this interactive, serious game, teams of approximately eight interprofessional participants were provided with a fictitious patient case in a simulated hospital environment. Within a 45-minute time limit, students needed to use objects in the room to solve a series of puzzles to successfully complete the room by addressing all the patient's needs. A facilitated debrief following the activity allowed participants to reflect on their communication skills and teamwork during the experience. A total of thirty students across seven professions piloted the activity, and 181 students across five professions participated in the activity as part of an academic course. Feedback from students was collected on a seven-point Likert scale and revealed the value of an interprofessional escape room in academia. This report, which describes what appears to be the first interprofessional health care escape room within an IPE curriculum, demonstrates the value of the escape room in encouraging teamwork, facilitating communication, and promoting interprofessionalism.

Drug Therapy Problem Severity Following Hospitalization and Association With 30-Day Clinical Outcomes.

BACKGROUND: Improved understanding of how drug therapy problems (DTPs) contribute to rehospitalization is needed. OBJECTIVE: The primary objectives were to assess the association of DTP likelihood of harm (LoH) severity score, as measured by comprehensive medication management (CMM) pharmacist after hospital discharge, with 30-day risk of hospital readmission, observation visit, or emergency department visit, and to determine whether resolution of DTPs reduces 30-day risk. Secondary objectives were to determine if any eventswere associated with DTPs and preventability of events. METHODS: Data were collected for 365 patients who received CMM following hospitalization and had at least 1 DTP identified. Retrospective chart reviews were completed for 80 patients with subsequent events to assess associationg with a DTP and its preventability. RESULTS: For each 1-point increment in maximum LoH score, there was 10% higher risk of the composite end point (hazard ratio [HR]=1.10; 95% CI:0.97-1.26; P=0.13). When DTPs were resolved by the CMM pharmacist, the association was attenuated, with a HR of 1.15 (95% CI:0.96-1.38; P=0.12) when the DTP was unresolved and HR of 1.09 (95% CI:0.96-1.25; P=0.52) when resolved; for hospital readmission alone, the corresponding HRs were 1.23 (95% CI:1.00-1.53; P=0.05) and 1.05 (95% CI:0.87-1.27; P=0.60). Of 80 subsequent events, 44 were associated with a medication; 22 were considered preventable. Conclusion and Relevance: The LoH severity score was associated with risk of 30-day events. The strength of association was attenuated when DTPs were resolved by the CMM pharmacist. However, because of statistical uncertainty, larger studies are needed to confirm these patterns.

The student-run free clinic: an ideal site to teach interprofessional education?

Student-run free clinics (SRFCs) often include an interprofessional group of health professions students and preceptors working together toward the common goal of caring for underserved populations. Therefore, it would seem that these clinics would be an ideal place for students to participate in an interprofessional collaborative practice and for interprofessional education to occur. This article describes a prospective, observational cohort study of interprofessional attitudes and skills including communication and teamwork skills and attitudes about interprofessional learning, relationships and interactions of student volunteers in a SRFC compared to students who applied and were not accepted to the clinic and to students who never applied to the clinic. This study showed a decrease in attitudes and skills after the first year for all groups. Over the next two years, the total score on the survey for the accepted students was higher than the not accepted students. The students who were not accepted also became more similar to students who never applied. This suggests a protective effect against declining interprofessional attitudes and skills for the student volunteers in a SRFC. These findings are likely a function of the design of the clinical and educational experience in the clinic and of the length of contact the students have with other professions.

Use of automated reminder letters to improve diabetes management in primary care: outcomes of a quality improvement initiative.

BACKGROUND: Effective management of patients with diabetes mellitus (DM) can be time-consuming and costly. One patient-centred quality improvement strategy is to generate reminder letters to prompt patient action(s), but this strategy's effect on DM outcomes is uncertain. AIM: To determine whether using the electronic medical record to automatically generate reminder letters for patients not meeting recommended DM targets is associated with improvement in practice level quality metrics for DM management. METHODS: Over 15 months, letters were sent monthly to all patients with DM in a large, urban, primary care teaching practice whose records for haemoglobin A1c (HbA1c), low-density lipoprotein (LDL) or blood pressure (BP) indicated non-compliance with recommended levels and testing intervals. Logistic regression was used to analyse cross-sectional, practice-level differences in the proportion of patients meeting DM quality metrics (HbA1c < 7%, LDL < 100 mg/dl and BP < 130/80 mmHg; rates of checking each value within the last 12 months; and a composite of these five measures) across four time points: six months before the intervention, start of the intervention, end of the 15-month intervention period and six months after the intervention. RESULTS: The number of letters sent per month ranged from 284 to 392, representing 28-38% of all patients with DM. At the end of the intervention, patients' odds of being at goal were higher than before the intervention began for LDL < 100 mg/dl, and for HbA1c and LDL tested once within the last 12 months (or 1.24, P = 0.005; or 1.35, P = 0.03; or 1.48, P < 0.001, respectively). Post intervention, declines were seen in LDL checked within the last 12 months (or 0.76, P = 0.003) and in the composite endpoint (or 0.78, P = 0.005). CONCLUSIONS: The automated patient-reminder letter intervention was associated with modest improvements in several, but not all DM measures. This approach may be an effective tool for improving quality of care for patients with DM.

Centering Community Voices: Establishment of a Community Advisory Board at a Student-Run Free Clinic.

Student-run free clinics (SRFCs) are common throughout the U.S. and have potential to meet the needs of both health professions trainees and patients in underserved communities. Here, we describe our SRFC's initial process for recruiting, implementing, and evaluating a Community Advisory Board to better align clinic offerings with community needs.

Selecting a provider: what factors influence patients' decision making?

Each year consumers make a variety of decisions relating to their healthcare. Some experts argue that stronger consumer engagement in decisions about where to obtain medical care is an important mechanism for improving efficiency in healthcare delivery and financing. Consumers' ability and motivation to become more active decision makers are affected by several factors, including financial incentives and access to information. This study investigates the set of factors that consumers consider when selecting a provider, including attributes of the provider and the care experience and the reputation of the provider. Additionally, the study evaluates consumers awareness and use of formal sources of provider selection information. Our results from analyzing data from a survey of 467 patients at four clinics in Minnesota suggest that the factors considered of greatest importance include reputation of the physician and reputation of the healthcare organization. Contractual and logistical factors also play a role, with respondents highlighting the importance of seeing a provider affiliated with their health plan and appointment availability. Few respondents indicated that advertisements or formal sources of quality information affected their decision making. The key implication for provider organizations is to carefully manage referral sources to ensure that they consistently meet the needs of referrers. Excellent service to existing patients and to the network of referring physicians yields patient and referrer satisfaction that is critical to attracting new patients. Finally, organizations more generally may want to explore the capabilities of new media and social networking sites for building reputation.

Defining and Characterizing Frequent Attenders: Systematic Literature Review and Recommendations.

PURPOSE: To decrease cost and improve efficiency, health care organizations have focused on frequent attenders - patients with high health care utilization. Prior studies have investigated singular health care settings, used varying definitions of frequent attendance, and inconsistently identified factors correlated with frequent attendance. The purpose of this article is to suggest a uniform definition of frequent attenders for different health care settings and to determine factors correlated with frequent attendance. METHODS: This systematic review of three databases identified 2761 unique articles; 174 met inclusion criteria. Studies were analyzed for their definition of frequent attenders and factors associated with frequent attendance. RESULTS: Most studies defined frequent attenders by number of health care visits within a set time period (n=115) and top percentile cutoff (n=42). Based on averages across studies, we propose the following frequent attender definitions: for primary care, either the top 10th percentile or at least 10 visits in 12 months; for emergency room, at least 5 visits in 12 months; and for inpatient hospitalization, at least 4 admissions in 12 months. Common factors correlated with frequent attendance were mental health and chronic disease. CONCLUSIONS: We propose definitions of frequent attenders for three common health care settings: primary care, emergency room, and inpatient. Future studies should include mental health and chronic disease, among other factors, when studying this population. Adoption of these recommendations will allow comparisons across studies such that meta-analyses may better determine interventions for more appropriate health care utilization.

Characterizing the Community Collaborations of a Community-Based Student-Run Clinic.

INTRODUCTION: Community-based student-run free clinics (SRCs) can advance health on a community level by reaching populations not served by other organizations and serving as an access point to the healthcare system. However, little is known about the scope of community-engaged efforts undertaken by SRCs, including interorganizational partnerships and relationship-building activities. The primary objective of this study was to characterize the community collaborations of an interprofessional SRC located in a high-poverty area. METHODS: Qualitative data was collected through semi-structured interviews with key stakeholders, which included student volunteers holding leadership roles, representatives of community-based organizations, and current and former members of the community advisory board. RESULTS: Key informant interviews with student and community leaders offered insight into local community outreach activities and the community advisory board. Findings revealed opportunities to impact community health through more intentional collaboration and relationship-building. CONCLUSIONS: This exploratory study adds to literature suggesting that community-based SRCs can address service gaps in medically underserved communities while advancing community health through intentional community engagement.

Interprofessional Health Care Escape Room for Advanced Learners.

BACKGROUND: Interprofessional education is essential to ensure that health care graduates are prepared for collaborative practice. One way to prepare students for interprofessional practice is to expose them to interprofessional activities throughout their educational program. METHOD: In this article, we present the design and curricular implementation of an interprofessional health care escape room-a type of serious game in which teams of interprofessional participants were provided with a fictitious case. The participants were given 1 hour to work together to solve puzzles and create a postdischarge care plan for the patient. RESULTS: Seven hundred eighty-six students, across four professions, have participated in this experience as part of an academic course. The results were positive: 89.5% of participants found that the activity improved communication and teamwork, and 94.1% felt that team members were listened to. CONCLUSION: This report demonstrates the value of an interactive interprofessional activity for advanced learners. [J Nurs Educ. 2020;59(1):46-50.].

Teamwork in clinical reasoning - cooperative or parallel play?

Teamwork is fundamental for high-quality clinical reasoning and diagnosis, and many different individuals are involved in the diagnostic process. However, there are substantial gaps in how these individuals work as members of teams and, often, work is done in parallel, rather than in an integrated, collaborative fashion. In order to understand how individuals work together to create knowledge in the clinical context, it is important to consider social cognitive theories, including situated cognition and distributed cognition. In this article, the authors describe existing gaps and then describe these theories as well as common structures of teams in health care and then provide ideas for future study and improvement.

Effects of Accreditation Council for Graduate Medical Education work hour restrictions on medical student experience.

BACKGROUND: Residents have a major role in teaching students, yet little has been written about the effects of resident work hour restrictions on medical student education. OBJECTIVE: Our objective was to determine the effects of resident work hour restrictions on medical student education. DESIGN: We compared student responses pre work hour restrictions with those completed post work hour restrictions. PARTICIPANTS: Students on required Internal Medicine, Surgery, and Pediatric clerkships at the University of Minnesota. MEASUREMENTS: Two thousand eight hundred twenty-five student responses on end-of-clerkship surveys. RESULTS: Students reported 1.6 more hours per week of teaching by residents (95%CI 0.8-2.6) in the post work hours era. Students' ratings of the overall quality of their teaching on the ward did not change appreciably, 0.05 points' decline on a 5-point scale (P = .05). Like the residents, students worked fewer hours per week (avg. 1.5 hours less, 95%CI 0.4-2.6). There was no change in quality or quantity of attending teaching, students' relationships with their patients, or the overall value of the clerkships. CONCLUSIONS: Whereas resident duty hour restrictions at our institution have had minimal effect on students' ratings of the overall teaching quality, they do report being taught more by their residents. This may be a factor of decreased resident fatigue or an increased sense of well-being; but more study is needed to clarify the causes of our observations.

Changes in Health Professional Students' Attitudes Toward the Underserved: Impact of Extended Participation in an Interprofessional Student-Run Free Clinic.

This study assessed the impact of volunteering for 2 years in an interprofessional student-run free clinic (SRFC) on the attitudes of health professional students toward the medically underserved. The Health Professionals' Attitudes Toward the Homeless Inventory was administered to students from six different health professions at three time points: before, after 1 year, and after 2 years of volunteering in an SRFC. The results were compared to students who never applied to the SRFC and those who applied but were not accepted. Students who applied had similar attitude scores at baseline and differed significantly from those who did not apply. Although all three groups showed declining attitudes after the first year, students who volunteered had more favorable attitudes than the other two groups from this point forward. These results suggest that SRFCs have a protective effect against the declining attitudes toward the underserved that can occur as training progresses.

Seek and ye shall find: consumer search for objective health care cost and quality information.

Significant investments have been made in developing and disseminating health care provider cost and quality information on the Internet with the expectation that stronger consumer engagement will lead consumers to seek providers who deliver high-quality, low-cost care. However, prior research shows that the awareness and use of such information is low. This study investigates how the information search process may contribute to explaining this result. The analysis reveals that the Web sites most likely to be found by consumers are owned by private companies and provide information based on anecdotal patient experiences. Web sites less likely to be found have government or community-based ownership, are based on administrative data, and contain a mixture of quality, cost, and patient experience information. Searches for information on hospitals reveal more cost and quality information based on administrative data, whereas searches that focus on clinics or physicians are more likely to produce information based on patient narratives.

Comparative effectiveness of bariatric surgery and nonsurgical therapy in adults with type 2 diabetes mellitus and body mass index <35 kg/m2.

BACKGROUND: Outcomes of bariatric surgery in patients with a body mass index (BMI) <35 kg/m(2) have been an active area of investigation. We examined the comparative effectiveness of Roux-en-Y gastric bypass (RYGB) to routine medical management (nonsurgical controls; NSCs) in achieving appropriate targets defined by the American Diabetes Association for type 2 diabetes mellitus (T2DM) in patients with class I obesity (BMI 30.0-34.9 kg/m(2)) T2DM at 1 year. METHODS: We identified patients undergoing RYGB (N = 17) with both class I obesity and T2DM and compared them to similar NSC (N = 17) treated in the Primary Care Center. Data were collected at baseline and 1 year for systolic blood pressure (SBP), as well as blood levels for low-density lipoprotein (LDL) cholesterol and hemoglobin A1c (HbA1c). RESULTS: After RYGB, BMI decreased from 34.6 ± 0.8 kg/m(2) to 25.8 ± 2.5 kg/m(2) (P < .001) and HbA1c decreased from 8.2 ± 2.0% to 6.1 ± 2.7% (P < .001). The NSC cohort had no significant change in either BMI or HbA1c. SBP and LDL did not significantly change in either group. The RYGB group had a decrease in medication use compared to the NSC group (P < .001). The RYGB group ceased the use of antihypertensive and antihyperlipidemia medications by 1 year despite abnormal values. CONCLUSION: RYGB can be performed in patients with both a BMI <35 kg/m(2) and T2DM with better weight loss, glycemic control, and fewer antihyperglycemic medications than NSC. Inappropriate cessation of medications may partially explain the persistent increase in both SBP and LDL after RYGB.