Adapting a Medical School Cancer Research Education Program to the Virtual Environment: a Mixed-Methods Study.

With cancer incidence increasing worldwide, physicians with cancer research training are needed. The Scholars in Oncology-Associated Research (SOAR) cancer research education program was developed to train medical students in cancer research while exposing them to the breadth of clinical oncology. Due to the COVID-19 pandemic, SOAR transitioned from in-person in 2019 to virtual in 2020 and hybrid in 2021. This study investigates positive and negative aspects of the varying educational formats. A mixed-methods approach was used to evaluate the educational formats. Pre- and post-surveys were collected from participants to assess their understanding of cancer as a clinical and research discipline. Structured interviews were conducted across all three cohorts, and thematic analysis was used to generate themes. A total of 37 students participated in SOAR and completed surveys (2019 n = 11, 2020 n = 14, and 2021 n = 12), and 18 interviews were conducted. Understanding of oncology as a clinical (p < 0.01 for all) and research discipline (p < 0.01 for all) improved within all three cohorts. There was no difference between each cohort's improvement in research understanding (p = 0.6). There was no difference between each cohort's understanding of oncology-related disciplines as both clinical and research disciplines (p > 0.1 for all). Thematic analysis demonstrated that hybrid and in-person formats were favored over a completely virtual one. Our findings demonstrate that a medical student cancer research education program is effective using in-person or hybrid formats for research education, although virtual experiences may be suboptimal to learning about clinical oncology.

Sleep in Hospitalized Older Adults.

Hospitalization is a period of acute sleep deprivation for older adults due to environmental, medical, and patient factors. Although hospitalized patients are in need of adequate rest and recovery during acute illness, older patients face unique risks due to acute sleep loss during; hospitalization. Sleep loss in the hospital is associated with worse health outcomes, including; cardio-metabolic derangements and increased risk of delirium. Because older patients are at risk of; polypharmacy and medication side effects, a variety of nonpharmacological interventions are recommended first to improve sleep loss for hospitalized older adults.

Implementation of a Novel Medical School Multidisciplinary and Interprofessional Oncology Curriculum: a Mixed Method Study.

As the population of patients with cancer and survivors grows, physician knowledge of oncology clinical care and research is increasingly important. Despite this patient population growth, medical students and non-oncology physicians report insufficient oncologic and survivorship care training. First-year students at a single US medical school completing a summer research experience were invited to participate in integrated Scholars in Oncology-Associated Research (SOAR) program. SOAR seeks to broaden students' understanding of multidisciplinary and interprofessional oncology clinical care and research. SOAR consists of three components: structured didactics, multidisciplinary tumor board attendance, and interprofessional shadowing. A mixed-methods approach investigated whether student knowledge improved after SOAR. Thirty-three students enrolled in SOAR (20 in 2015, 13 in 2016) and completed pre-assessments. Twenty-five (75.8%) students completed SOAR and post-assessments. Self-reported understanding of clinical (2[2, 3] vs. 4[4], p < 0.01) and research oncology (2[2, 3] vs. 4[4], p < 0.01) improved after SOAR. Understanding of individual disciplines also significantly improved. When describing clinical oncology, responses written post-SOAR were more comprehensive, averaging 3.7 themes per response vs. 2.8 on pre-assessments (p = 0.03). There were more references to "survivorship" as a component of oncology on post-assessments (0[0.0%] vs. 7[28.0%], p < 0.01) and "screening/prevention" (2[6.1%] vs. 7[28.0%], p = 0.03). Additionally, students more often described cancer care as a continuum on post-assessments (4[12.1%] vs. 11[44.0%], p = 0.01). A structured didactic and experiential introduction to oncology, SOAR, was successfully piloted. SOAR improved participant understanding of oncology and its distinct clinical and research disciplines. Future work will focus on expanding SOAR into a longitudinal oncology curriculum.

Bridging the Gap: Interdepartmental Quality Improvement and Patient Safety Curriculum Created by Hospital Leaders, Faculty, and Trainees.

BACKGROUND: The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review recommends that quality improvement/patient safety (QI/PS) experts, program faculty, and trainees collectively develop QI/PS education. OBJECTIVE: Faculty, hospital leaders, and resident and fellow champions at the University of Chicago designed an interdepartmental curriculum to train postgraduate year 1 (PGY-1) residents on core QI/PS principles, measuring outcomes of knowledge, attitudes, and event reporting. METHODS: The curriculum consisted of 3 sessions: PS, quality assessment, and QI. Faculty and resident and fellow leaders taught foundational knowledge, and hospital leaders discussed institutional priorities. PGY-1 residents attended during protected conference times, and they completed in-class activities. Knowledge and attitudes were assessed using pretests and posttests; graduating residents (PGY-3-PGY-8) were controls. Event reporting was compared to a concurrent control group of nonparticipating PGY-1 residents. RESULTS: From 2015 to 2017, 140 interns in internal medicine (49%), pediatrics (33%), and surgery (13%) enrolled, with 112 (80%) participating and completing pretests and posttests. Overall, knowledge scores improved (44% versus 57%, P < .001), and 72% of residents demonstrated increased knowledge. Confidence comprehending quality dashboards increased (13% versus 49%, P < .001). PGY-1 posttest responses were similar to those of 252 graduate controls for accessibility of hospital leaders, filing event reports, and quality dashboards. PGY-1 residents in the QI/PS curriculum reported more patient safety events than PGY-1 residents not exposed to the curriculum (0.39 events per trainee versus 0.10, P < .001). CONCLUSIONS: An interdepartmental curriculum was acceptable to residents and feasible across 3 specialties, and it was associated with increased event reporting by participating PGY-1 residents.

Sleep in Hospitalized Older Adults.

Hospitalization is a period of acute sleep deprivation for older adults owing to environmental, medical, and patient factors. Although hospitalized patients are in need of adequate rest and recovery during acute illness, older patients face unique risks owing to acute sleep loss during hospitalization. Sleep loss in the hospital is associated with worse health outcomes, including cardiometabolic derangements and an increased risk of delirium. Because older patients are at risk of polypharmacy and medication side effects, a variety of nonpharmacologic interventions are recommended first to improve sleep loss for hospitalized older adults.

Educational video to improve CPAP use in patients with obstructive sleep apnoea at risk for poor adherence: a randomised controlled trial.

BACKGROUND: Suboptimal adherence to CPAP limits its clinical effectiveness in patients with obstructive sleep apnoea (OSA). Although rigorous behavioural interventions improve CPAP adherence, their labour-intensive nature has limited widespread implementation. Moreover, these interventions have not been tested in patients at risk of poor CPAP adherence. Our objective was to determine whether an educational video will improve CPAP adherence in patients at risk of poor CPAP adherence. METHODS: Patients referred by clinicians without sleep medicine expertise to an urban sleep laboratory that serves predominantly minority population were randomised to view an educational video about OSA and CPAP therapy before the polysomnogram, or to usual care. The primary outcome was CPAP adherence during the first 30 days of therapy. Secondary outcomes were show rates to sleep clinic (attended appointment) and 30-day CPAP adherence after the sleep clinic visit date. RESULTS: A total of 212 patients met the eligibility criteria and were randomised to video education (n=99) or to usual care (n=113). There were no differences in CPAP adherence at 30 days (3.3, 95% CI 2.8 to 3.8 hours/day video education; vs 3.5, 95% CI 3.1 to 4.0 hours/day usual care; p=0.44) or during the 30 days after sleep clinic visit. Sleep clinic show rate was 54% in the video education group and 59% in the usual care group (p=0.41). CPAP adherence, however, significantly worsened in patients who did not show up to the sleep clinic. CONCLUSIONS: In patients at risk for poor CPAP adherence, an educational video did not improve CPAP adherence or show rates to sleep clinic compared with usual care. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02553694.

How Prepared Are Medical and Nursing Students to Identify Common Hazards in the Intensive Care Unit?

RATIONALE: Care in the hospital is hazardous. Harm in the hospital may prolong hospitalization, increase suffering, result in death, and increase costs of care. Although the interprofessional team is critical to eliminating hazards that may result in adverse events to patients, professional students' formal education may not prepare them adequately for this role. OBJECTIVES: To determine if medical and nursing students can identify hazards of hospitalization that could result in harm to patients and to detect differences between professions in the types of hazards identified. METHODS: Mixed-methods observational study of graduating nursing (n = 51) and medical (n = 93) students who completed two "Room of Horrors" simulations to identify patient safety hazards. Qualitative analysis was used to extract themes from students' written hazard descriptions. Fisher's exact test was used to determine differences in frequency of hazards identified between groups. RESULTS: Identification of hazards by students was low: 66% did not identify missing personal protective equipment for a patient on contact isolation, and 58% did not identify a medication administration error (medication hanging for a patient with similar name). Interprofessional differences existed in how hazards were identified: medical students noted that restraints were not indicated (73 vs. 2%, P < 0.001), whereas nursing students noted that there was no order for the restraints (58.5 vs. 0%, P < 0.0001). Nursing students discovered more issues with malfunctioning or incorrectly used equipment than medical students. Teams performed better than individuals, especially for hazards in the second simulation that were similar to those in the first: need to replace a central line with erythema (73% teams identified) versus need to replace a peripheral intravenous line (10% individuals, P < 0.0001). Nevertheless, teams of students missed many intensive care unit-specific hazards: 54% failed to identify the presence of pressure ulcers; 85% did not notice high tidal volumes on the ventilator; and 90% did not identify the absence of missing spontaneous awakening/breathing trials and absent stress ulcer prophylaxis. CONCLUSIONS: Graduating nursing and medical students missed several hazards of hospitalization, especially those related to the intensive care unit. Orientation for residents and new nurses should include education on hospitalization hazards. Ideally, this orientation should be interprofessional to allow appreciation for each other's roles and responsibilities.

Prevalence of impaired memory in hospitalized adults and associations with in-hospital sleep loss.

BACKGROUND: Effective inpatient teaching requires intact patient memory, but studies suggest hospitalized adults may have memory deficits. Sleep loss among inpatients could contribute to memory impairment. OBJECTIVE: To assess memory in older hospitalized adults, and to test the association between sleep quantity, sleep quality, and memory, in order to identify a possible contributor to memory deficits in these patients. DESIGN: Prospective cohort study. SETTING: General medicine and hematology/oncology inpatient wards. PATIENTS: Fifty-nine hospitalized adults at least 50 years of age with no diagnosed sleep disorder. MEASUREMENTS: Immediate memory and memory after a 24-hour delay were assessed using a word recall and word recognition task from the University of Southern California Repeatable Episodic Memory Test. A vignette-based memory task was piloted as an alternative test more closely resembling discharge instructions. Sleep duration and efficiency overnight in the hospital were measured using actigraphy. RESULTS: Mean immediate recall was 3.8 words out of 15 (standard deviation = 2.1). Forty-nine percent of subjects had poor memory, defined as immediate recall score of 3 or lower. Median immediate recognition was 11 words out of 15 (interquartile range [IQR] = 9-13). Median delayed recall score was 1 word, and median delayed recognition was 10 words (IQR = 8-12). In-hospital sleep duration and efficiency were not significantly associated with memory. The medical vignette score was correlated with immediate recall (r = 0.49, P < 0.01). CONCLUSIONS: About half of the inpatients studied had poor memory while in the hospital, signaling that hospitalization might not be an ideal teachable moment. In-hospital sleep was not associated with memory scores.

Insights into inpatients with poor vision: A high value proposition.

BACKGROUND: Vision impairment is an under-recognized risk factor for adverse events among hospitalized patients, yet vision is neither routinely tested nor documented for inpatients. Low-cost ($8 and up) nonprescription "readers" may be a simple, high-value intervention to improve inpatients' vision. We aimed to study initial feasibility and efficacy of screening and correcting inpatients' vision. METHODS: From June 2012 through January 2014 we began testing whether participants' vision corrected with nonprescription lenses for eligible participants failing a vision screen (Snellen chart) performed by research assistants (RAs). Descriptive statistics and tests of comparison, including t tests and χ(2) tests, were used when appropriate. All analyses were performed using Stata version 12 (StataCorp, College Station, TX). RESULTS: Over 800 participants' vision was screened (n = 853). Older (≥65 years; 56%) participants were more likely to have insufficient vision than younger (<65 years; 28%; P < 0.001). Nonprescription readers corrected the majority of eligible participants' vision (82%, 95/116). DISCUSSION: Among an easily identified subgroup of inpatients with poor vision, low-cost readers successfully corrected most participants' vision. Hospitalists and other clinicians working in the inpatient setting can play an important role in identifying opportunities to provide high-value care related to patients' vision.

Wisdom of the crowd: bright ideas and innovations from the teaching value and choosing wisely challenge.

PROBLEM: Medical education has been cited as both part of the problems facing, and part of the solution to reforming, the increasingly challenging U.S. health care system which is fraught with concerns regarding the quality and affordability of care. To teach value in ways that are impactful, sustainable, and scalable, the best and brightest ideas need to be shared such that educators can build on successful existing innovations. APPROACH: To identify the most promising innovations and bright ideas for teaching value to clinical trainees, the authors hosted the "Teaching Value and Choosing Wisely Challenge." The challenge used crowdsourcing methods to solicit scalable, pedagogical approaches from across North America, and then draw generalizable lessons. OUTCOMES: The authors received 74 submissions (28 innovations; 46 bright ideas) from 14 students, 20 residents/fellows, 38 faculty members (ranging from instructors to full professors), and 2 nonclinical administrators. Submissions represented 14 clinical disciplines including internal medicine, emergency medicine, surgery, pediatrics, obstetrics-gynecology, laboratory medicine, and pharmacy. Thirty-nine abstracts focused on graduate medical education, 15 addressed undergraduate medical education, and 20 applied to both. NEXT STEPS: The authors have solicited, shared, and described solutions for teaching high-value care to medical trainees. Challenge participants demonstrated commitment to improving value and ingenuity in addressing professional barriers to change. Further success requires strong local faculty champions and willing trainee participants. Additionally, the use of data to demonstrate the collective positive impact of these ideas and programs will be critical for sustaining pedagogical changes in the health professions.

IBCD: development and testing of a checklist to improve quality of care for hospitalized general medical patients.

BACKGROUND: Several studies have demonstrated the usefulness of medical checklists to improve quality of care in surgery and the ICU. The feasibility, effectiveness, and sustainability of a checklist was explored. METHODS: Literature on checklists and adherence to quality indicators in general medicine was reviewed to develop evidence-based measures for the IBCD checklist: (I) pneumococcal immunization, (B) pressure ulcers (bedsores), (C) catheter-associated urinary tract infections (CAUTIs), and (D) deep venous thrombosis (DVT) were considered conditions highly relevant to the quality of care in general medicine inpatients. The checklist was used by attending physicians during rounds to remind residents to perform four actions related to these measures. Charts were audited to document actions prompted by the checklist. RESULTS: The IBCD checklist was associated with significantly increased documentation of and adherence to care processes associated with these four quality indicators. Seventy percent (46/66) of general medicine teams during the intervention period of July 2010-March 2011 voluntarily used the IBCD checklist for 1,168 (54%) of 2,161 patients. During the intervention period, average adherence for all four checklist items increased from 68% on admission to 82% after checklist use (p < .001). Average adherence after checklist use was also higher when compared to a historical control group from one year before implementation (82% versus 50%, p < .0001). In the six weeks after the checklist was transitioned to the electronic medical record, IBCD was noted in documentation of 133 (59%) of 226 patients admitted to general medicine. CONCLUSION: A checklist is a useful and sustainable tool to improve adherence to, and documentation of, care processes specific to quality indicators in general medicine.

Sleep-disordered breathing and postoperative outcomes after bariatric surgery: analysis of the nationwide inpatient sample.

BACKGROUND: Sleep-disordered breathing (SDB), also known as obstructive sleep apnea (OSA), has been increasingly recognized as a possible risk factor for adverse perioperative outcomes in non-bariatric surgeries. However, the impact of SDB on postoperative outcomes in patients undergoing bariatric surgery remains less clearly defined. We hypothesized that SDB would be independently associated with worse postoperative outcomes. METHODS: Data were obtained from the Nationwide Inpatient Sample database and included a total of 91,028 adult patients undergoing bariatric surgeries from 2004 to 2008. The primary outcomes were in-hospital death, total charges, and length of stay. There were two secondary outcomes of interest: respiratory and cardiac complications. Regression models were fitted to assess the independent association between SDB and the outcomes of interest. RESULTS: SDB was independently associated with decreased mortality (OR = 0.34, 95% CI = 0.23-0.50, p < 0.001), total charges (-$869, p < 0.001), and length of stay (-0.25 days, p < 0.001). SDB was independently associated with significantly increased odds ratio of emergent endotracheal intubation (OR = 4.35, 95% CI = 3.97-4.77, p < 0.001), noninvasive ventilation (OR = 14.12, 95% CI = 12.09-16.51, p < 0.001), and atrial fibrillation (OR = 1.25, 95% CI = 1.11-1.41, p < 0.001). Emergent intubation occurred significantly earlier in the postoperative course in patients with SDB. Although non-SDB patients had an overall lower risk of emergent intubation compared to SDB patients, their outcomes were significantly worse when they did get emergently intubated. CONCLUSIONS: In this large nationally representative sample, despite the increased association of SDB/OSA with postoperative cardiopulmonary complications, the diagnosis of SDB/OSA was negatively, rather than positively, associated with in-hospital mortality and resource use.

Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the nationwide inpatient sample.

BACKGROUND: Systematic screening and treatment of sleep-disordered breathing (SDB) or obstructive sleep apnea (OSA) in presurgical patients would impose a significant cost burden; therefore, it is important to understand whether SDB is associated with worse postoperative outcomes. We sought to determine the impact of SDB on postoperative outcomes in patients undergoing four specific categories of elective surgery (orthopedic, prostate, abdominal, and cardiovascular). The primary outcomes were in-hospital death, total charges, and length of stay (LOS). Two secondary outcomes of interest were respiratory and cardiac complications. METHODS: Data were obtained from the Nationwide Inpatient Sample database. Regression models were fitted to assess the independent association between SDB and the outcomes of interest. RESULTS: The cohort included 1,058,710 hospitalized adult patients undergoing elective surgeries between 2004 and 2008. SDB was independently associated with decreased mortality in the orthopedic (OR, 0.65; 95% CI, 0.45-0.95; P = .03), abdominal (OR, 0.38; 95% CI, 0.22-0.65; P = .001), and cardiovascular surgery groups (OR, 0.54; 95% CI, 0.40-0.73; P < .001) but had no impact on mortality in the prostate surgery group. SDB was independently associated with a small, but statistically significant increase in estimated mean LOS by 0.14 days (P < .001) and estimated mean total charges by $860 (P < .001) in the orthopedic surgery group but was not associated with increased LOS or total charges in the prostate surgery group. In the abdominal and cardiovascular surgery groups, SDB was associated with a significant decrease in adjusted mean LOS of 1.1 days and 0.35 days, respectively (P < .001 for both groups), and adjusted mean total charges of $3,814 and $4,592, respectively (P < .001 for both groups). SDB was independently associated with a significantly increased OR for emergent intubation and mechanical ventilation, noninvasive ventilation, and atrial fibrillation in all four surgical categories. Emergent intubation occurred significantly earlier in the postoperative course in patients with SDB. In the subgroup of patients requiring emergent intubation, LOS, total charges, pneumonias, and in-hospital death were significantly higher in those without SDB. CONCLUSIONS: In this large national study, despite the increased independent association of SDB with postoperative cardiopulmonary complications, the diagnosis of SDB was not independently associated with an increased rate of in-hospital death. SDB had a mixed impact on LOS and total charges by surgical category.

Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors.

PURPOSE: To assess internal medicine (IM) and surgery program directors' views of the likely effects of the 2011 Accreditation Council for Graduate Medical Education duty hours regulations. METHOD: In fall 2010, investigators surveyed IM and surgery program directors, assessing their views of the likely impact of the 2011 duty hours standards on learning environment, workload, education opportunities, program administration, and patient outcomes. RESULTS: Of 381 IM program directors, 287 (75.3%) responded; of 225 surgery program directors, 118 (52.4%) responded. Significantly more surgeons than internists indicated that the new regulations would likely negatively impact learning climate, including faculty morale and residents' relationships (P < .001). Most leaders in both specialties (80.8% IM, 80.2% surgery) felt that the regulations would likely increase faculty workload (P = .73). Both IM (82.2%) and surgery (96.6%) leaders most often rated, of all education opportunities, first-year resident clinical experience to be adversely affected (P < .001). Respondents from both specialties indicated that they will hire more nonphysician/midlevel providers (59.5% IM, 89.0% surgery, P < .001) and use more nonteaching services (66.8% IM, 70.1% surgery, P = .81). Respondents expect patient safety (45.1% IM, 76.9% surgery, P < .001) and continuity of care (83.6% IM across all training levels, 97.5% surgery regarding first-year residents) to decrease. CONCLUSIONS: IM and surgery program directors agree that the 2011 duty hours regulations will likely negatively affect the quality of the learning environment, workload, education opportunities, program administration, and patient outcomes. Careful evaluation of actual impact is important.

A systematic review: the effect of clinical supervision on patient and residency education outcomes.

PURPOSE: To summarize the literature regarding the effect of clinical supervision on patient and educational outcomes, especially in light of the recent (2010) Accreditation Council for Graduate Medical Education report that recommends augmented supervision to improve resident education and patient safety. METHOD: The authors searched the English-language literature from 1966 to 2010 using electronic databases and a hand search. They included studies that described a controlled design, and they have relayed the effects of supervision on patient- and education-related outcomes. Two authors abstracted prescribed data from the reviewed studies. The authors rated the quality of each study using the Medical Education Research Study Quality Instrument. RESULTS: Twenty-four articles across a variety of specialties (i.e., psychiatry, emergency medicine, surgery, anesthesia, and internal medicine) met inclusion criteria. Studies demonstrated that enhanced supervision in already-supervised activities resulted in improved patient- or education-related outcomes. Studies were limited by small sample sizes, nonrandomized designs, and a lack of objective measures of clinical supervision. CONCLUSIONS: Enhanced clinical supervision of trainees has been associated with improved patient- and education-related outcomes in published studies. Future work should focus on developing validated measures of the effects of clinical supervision.

A resident-led quality improvement initiative to improve obesity screening.

Instruction on quality improvement (QI) methods is required as part of residency education; however, there is limited evidence regarding whether internal medicine residents can improve patient care using these methods. Because obesity screening is not done routinely in clinical practice, residents aimed to improve screening using QI techniques. Residents streamlined body mass index (BMI) documentation, created educational materials about obesity, and launched an obesity screening QI initiative in a residency clinic. Residents designed plan-do-study-act cycles focused on increasing awareness and maintaining improvements in screening over a 1-year period. Documentation rates were collected at baseline, 2 weeks, 6 months, and 1 year post-intervention. At 1 year, obesity treatment rates also were collected. BMI documentation rates after 1 year were higher than baseline (43% vs 4%, P < .0001). In obese patients, BMI documentation was associated with lifestyle counseling (34% vs 14%, P < .01). An internal medicine resident-led QI project targeting obesity can improve screening.