Exploring Ward Team Handoffs of Overnight Admissions: Key Lessons from Field Observations.

BACKGROUND: The diagnostic process is a dynamic, team-based activity that is an important aspect of ward rounds in teaching hospitals. However, few studies have examined how academic ward teams operate in areas such as diagnosis in the handoff of overnight admissions during ward rounds. This study draws key lessons from team interactions in the handoff process during ward rounds. OBJECTIVE: To describe how ward teams operate in the handoff of patients admitted overnight during ward rounds, and to characterize the role of the bedside patient evaluation in this context. DESIGN: A qualitative ethnographic approach using field observations and documentary analysis. PARTICIPANTS: Attending physicians, medical residents, and medical students on general medicine services in a single teaching hospital. APPROACH: Thirty-five hours of observations were undertaken over a 4-month period. We purposively approached a diverse group of attendings who cover a range of clinical teaching experience, and obtained informed consent from all ward team members and observed patients. Thirty patient handoffs were observed across 5 ward teams with 45 team members. We conducted thematic analysis of researcher field notes and electronic health record documents using social cognitive theories to characterize the dynamic interactions occurring in the real clinical environment. KEY RESULTS: Teams spent less time during ward rounds on verifying history and physical examination findings, performing bedside evaluations, and discussing differential diagnoses than other aspects (e.g., reviewing patient data in conference rooms) in the team handoff process of overnight admissions. Several team-based approaches to diagnosis and bedside patient evaluations were observed, including debriefing for learning and decision-making. CONCLUSIONS: This study highlights potential strengths and missed opportunities for teaching, learning, and engaging directly with patients in the ward team handoff of patients admitted overnight. These findings may inform curriculum development, faculty training, and patient safety research.

Data Science as a Core Competency in Undergraduate Medical Education in the Age of Artificial Intelligence in Health Care.

The increasingly sophisticated and rapidly evolving application of artificial intelligence in medicine is transforming how health care is delivered, highlighting a need for current and future physicians to develop basic competency in the data science that underlies this topic. Medical educators must consider how to incorporate central concepts in data science into their core curricula to train physicians of the future. Similar to how the advent of diagnostic imaging required the physician to understand, interpret, and explain the relevant results to patients, physicians of the future should be able to explain to patients the benefits and limitations of management plans guided by artificial intelligence. We outline major content domains and associated learning outcomes in data science applicable to medical student curricula, suggest ways to incorporate these themes into existing curricula, and note potential implementation barriers and solutions to optimize the integration of this content.

Effects of a focused patient-centered care curriculum on the experiences of internal medicine residents and their patients.

BACKGROUND: Traditional residency training may not promote competencies in patient-centered care. AIM: To improve residents' competencies in delivering patient-centered care. SETTING/PARTICIPANTS: Internal medicine residents at a university-based teaching hospital in Baltimore, Maryland. PROGRAM DESCRIPTION: One inpatient team admitted half the usual census and was exposed to a multi-modal patient-centered care curriculum to promote knowledge of patients as individuals, improve patient transitions of care, and reduce barriers to medication adherence. PROGRAM EVALUATION: Annual resident surveys (N = 40) revealed that the intervention was judged as professionally valuable (90%) and important to their training (90%) and offered experiences not available during other rotations (88%). Compared to standard inpatient rotation evaluations (n = 163), intervention rotation evaluations (n = 51) showed no differences in ratings for traditional medical learning, but higher ratings for improving how housestaff address patient medication adherence, communicate with patients about post-hospital transition of care, and know their patients as people (all p < 0.01). On post-discharge surveys, patients from the intervention team (N = 177, score 90.4, percentile ranking 97%) reported greater satisfaction with physicians than patients on standard teams (N = 924, score 86.1, percentile ranking 47%) p < 0.01). DISCUSSION: A patient-centered inpatient curriculum was associated with higher satisfaction ratings in patient-centered domains by internal medicine residents and with higher satisfaction ratings of their physicians by patients. Future research will explore the intervention's impact on clinical outcomes.

Observation tool to measure patient-centered behaviors on rounds in an academic medical center.

OBJECTIVE: As part of a quality improvement project, we developed and employed an observation checklist to measure patient-centered behaviors during daily rounds to assess the frequency of patient-centered behaviors among a patient-centered care (PCC) team and standard team (ST) rounds. PATIENTS AND METHODS: On four general medicine service (GMS) teaching teams at an urban academic medical center in which housestaff rotate, we utilized an observation checklist to assess the occurrence of eight behaviors on inpatient daily rounds. The checklist covered domains of patient-centered communication, etiquette-based behaviors, and shared decision-making. One GMS team is guided by a PCC curriculum that emphasizes patient-centered communication strategies, but not specifically behaviors during bedside rounds. RESULTS: Between August 2018 and May 2019 a trained observer completed 448 observations of patient rounding encounters using the checklist. Across all teams, 46.0% of the 8 behaviors were performed when possible, with more done on the PCC team (58.0%) than ST (42.0%), p < 0.01. CONCLUSIONS: Performance of patient-centered behaviors during daily rounds was low overall. Despite having no specific instruction on daily rounds, patient-centered behaviors were more frequent among the teams which were part of a PCC curriculum. However, the frequency of observed behaviors was modest, suggesting that more explicit efforts to change rounding behaviors are needed. Our observational checklist may be a tool to assist in future interventions to improve patient-centered behaviors on daily rounds.

Major concerns about internal medicine: insights from program directors.

OBJECTIVE: To better understand and characterize the challenges facing internal medicine from the perspective of internal medicine residency program directors. METHODS: In 2007, internal medicine program directors were surveyed by the Association of Program Directors in Internal Medicine (APDIM). An open-ended question asked: "What are your major concerns regarding internal medicine?" Responses to this question were independently coded by two investigators and compared for agreement. Content analysis identified several major themes related to their concerns. RESULTS: Of the 236 program directors completing the survey, 186 (79%) answered the question and explained their concerns. Approximately one half of the informants were general internists. There was a fairly even distribution among assistant, associate, and professor ranking. All regions of the country were represented. Five themes emerged as the program directors' major concerns about internal medicine: waning interest in internal medicine, especially primary care; onerous regulatory oversight; economic pressures; the eighty-hour work week; and fragmentation within internal medicine. CONCLUSION: By virtue of their role, internal medicine residency directors gain a unique understanding about the core elements that contribute to declining interest in careers in internal medicine, which is particularly relevant given the current primary care workforce crisis. Collaboration among stakeholders that can influence healthcare policy to address these concerns about internal medicine will be necessary to revive interest in the field.

Delivering Personalized Care at a Distance: How Telemedicine Can Foster Getting to Know the Patient as a Person.

The promise of precision medicine is based on the use of new technologies to better characterize patients by defining individuals in the areas of genomics, proteomics, metabolomics and other aspects of biologic variability. Wise application of modern technology can similarly transform health visits with patients, allowing for better characterization of the patient's individual life circumstances than possible in a traditional office visit. The use of, and experience with, telemedicine have increased significantly during the COVID-19 pandemic. Patients and clinicians report high satisfaction with telemedicine, and the quality of communication and patient-centeredness experienced in this setting are both rated highly. In this article, we explore the benefits offered by telemedicine in facilitating personalized care with particular focus on telemedicine delivered by video platforms. We propose strategies and skills specific to the effective implementation of personalized telemedicine, drawing on literature in patient-centered communication and home visits. While traditional in-person office visits continue to offer important opportunities such as thorough physical examination and the potential for enhanced non-verbal communication, telemedicine offers many important advantages that can facilitate the process of getting to know the patient as a person.

Feasibility of clinical performance assessment of medical students on a virtual sub-internship in the United States.

We aimed to determine whether it was feasible to assess medical students as they completed a virtual sub-internship. Six students (out of 31 who completed an in-person sub-internship) participated in a 2-week virtual sub-internship, caring for patients remotely. Residents and attendings assessed those 6 students in 15 domains using the same assessment measures from the in-person sub-internship. Raters marked "unable to assess" in 75/390 responses (19%) for the virtual sub-internship versus 88/3,405 (2.6%) for the in-person sub-internship (P=0.01), most frequently for the virtual sub-internship in the domains of the physical examination (21, 81%), rapport with patients (18, 69%), and compassion (11, 42%). Students received complete assessments in most areas. Scores were higher for the in-person than the virtual sub-internship (4.67 vs. 4.45, P<0.01) for students who completed both. Students uniformly rated the virtual clerkship positively. Students can be assessed in many domains in the context of a virtual sub-internship.

Effects on Physician Practice After Exposure to a Patient-Centered Care Curriculum During Residency.

BACKGROUND: A novel patient-centered curricular experience was implemented in an internal medicine residency program in 2007. There is little published evidence that what is taught in residency affects practice after graduation. OBJECTIVE: We sought to evaluate whether graduates perceived any long-term effects of participation in this patient-centered curriculum. METHODS: From July to September 2015, a web-based survey with quantitative and qualitative components was sent to graduates of the program to assess self-reported effects of this curriculum on current practice. Graduates spent 2 to 8 weeks on the intervention team during their training. Responses to open-ended questions were independently coded by 2 investigators, using the editing analysis method. Emergent themes and representative quotes are reported. RESULTS: Of 150 residents who completed at least 1 year of training from 2007 to 2014, 94 of 110 (85%) with available email addresses responded to this survey. Of respondents, 21 (22%) were still in fellowship training, and 71 (76%) were in full-time practice. The majority responded "a great deal" when asked if the experience was valuable to their training as a physician (72 of 94, 77%) or influenced their practice (59 of 94, 63%). Free-text comments indicate that residents felt the experience enhanced their understanding of social determinants of health, communication skills, relationship building, and ability to tailor treatments to individual patients. CONCLUSIONS: Internal medicine residency graduates reported that exposure to a curriculum focused on knowing patients as individuals had important enduring effects on their practice.

The Effect of a Personalized Approach to Patient Education on Heart Failure Self-Management.

: Personalized tools relevant to an individual patient's unique characteristics may be an important component of personalized health care. We randomized 97 patients hospitalized with acute decompensated heart failure to receive a printout of an ultrasound image of their inferior vena cava (IVC) with an explanation of how the image is related to their fluid status (n = 50) or to receive no image and only generic heart failure information (n = 47). Adherence to medications, low-sodium diet, and daily weight measurement at baseline and 30 days after discharge were assessed using the Medical Outcomes Study Specific Adherence Scale, modified to a three-item version for heart failure (HF), (MOSSAS-3HF, maximum score = 15, indicating adherence all of the time). The baseline MOSSAS-3HF scores (mean ± standard deviation (SD)) were similar for intervention and control groups (7.4 ± 3.4 vs. 6.4 ± 3.7, p = 0.91). The MOSSAS-3HF scores improved for both groups but were not different at 30 days (11.8 ± 2.8 vs. 11.7 ± 3.0, p = 0.90). Survival without readmission or emergency department (ED) visit at 30 days was similar (82.6% vs. 84.1%, p = 0.85). A personalized HF tool did not affect rates of self-reported HF treatment adherence or survival without readmission or ED visit.

Medical students' perceptions of the patient-centredness of the learning environment.

BACKGROUND: Patient-centred care is an important aspect of quality health care. The learning environment may impact medical students' adoption of patient-centred behaviours. METHODS: All medical students at a single institution received an anonymous, modified version of the Communication, Curriculum, and Culture instrument that measures patient-centredness in the training environment along three domains: role modelling, students' experience, and support for patient-centred behaviours. We compared domain scores and individual items by class year and gender, and qualitatively analyzed responses to two additional items that asked students to describe experiences that demonstrated varying degrees of patient-centredness. RESULTS: Year 1 and 2 students reported greater patient-centredness than year 3 and 4 students in each domain: role modelling (p = 0.03), students' experience (p = <0.001), and support for patient-centred behaviours (p < 0.001). Female students reported less support for patient-centred behaviours compared with male students (p = 0.03). Qualitative analysis revealed that explicit patient-centred curricula and positive role modelling fostered patient-centredness. Themes relating to low degrees of patient-centredness included negative role modelling and students being discouraged from being patient-centred. CONCLUSIONS: Students' perceptions of the patient-centredness of the learning environment decreased as students progressed through medical school, despite increasing exposure to patients. Qualitative analysis found that explicit patient-centred curricula cultivated patient-centred attitudes. Role modelling impacted student perceptions of patient-centredness within the learning environment.

Chest pain in a young basketball player.

A 32-year-old man was elbowed in the chest while fighting for a rebound in a recreational basketball game. He fell to the ground and his chest ached from the blow. Four days later he developed more severe chest pressure with dyspnea and came to the hospital. His chest wall was tender and his pulse slow, but the remainder of his physical examination was normal. Electrocardiogram showed sinus bradycardia, first-degree atrioventricular (AV) block, and occasional isorhythmic AV dissociation, but no ischemic ST-T changes. Cardiac troponin I rose to 1.74 ng/mL (normal <0.50). The patient therefore underwent coronary angiography, showing spiral dissection of the right coronary artery with extensive thrombus filling the distal portion of the vessel. Stenting was unsuccessful in restoring flow. This case highlights the potential dangers of blunt chest trauma in recreational sports and shows how angiography can distinguish myocardial contusion from coronary artery dissection.

Telephone calls to patients after discharge from the hospital: an important part of transitions of care.

BACKGROUND: Teaching interns patient-centered communication skills, including making structured telephone calls to patients following discharge, may improve transitions of care. OBJECTIVE: To explore associations between a patient-centered care (PCC) curriculum and patients' perspectives of the quality of transitional care. METHODS: We implemented a novel PCC curriculum on one of four inpatient general medicine resident teaching teams in which interns make post-discharge telephone calls to patients, contact outpatient providers, perform medication adherence reviews, and engage in patient-centered discharge planning. Between July and November of 2011, we conducted telephone surveys of patients from all four teaching teams within 30 days of discharge. In addition to asking if patients received a call from their hospital physician (intern), we administered the 3-Item Care Transitions Measure (CTM-3), which assesses patients' perceptions of preparedness for the transition from hospital to home (possible score range 0-100). RESULTS: The CTM-3 scores (mean±SD) of PCC team patients and standard team patients were not significantly different (82.4±17.3 vs. 79.6±17.6, p=0.53). However, regardless of team assignment, patients who reported receiving a post-discharge telephone call had significantly higher CTM-3 scores than those who did not (84.7±16.0 vs. 78.2±17.4, p=0.03). Interns exposed to the PCC curriculum called their patients after discharge more often than interns never exposed (OR=2.78, 95% CI [1.25, 6.18], p=0.013). CONCLUSIONS: The post-discharge telephone call, one element of PCC, was associated with higher CTM-3 scores--which, in turn, have been shown to lessen patients' risk of emergency department visits within 30 days of discharge.