Use of Chart-Stimulated Recall to Explore Uncertainty in Medical Decision-Making Among Senior Internal Medicine Residents.

BACKGROUND: Uncertainty is common and impacts both patients and clinicians. The approach to uncertainty in medical trainees may be distinct from that of practicing clinicians and has important implications for medical education. OBJECTIVE: Describe trainee approach to uncertainty with the use of chart-stimulated recall (CSR)-based interviews, as well as the utility of such interviews in promoting reflection about decision-making among senior internal medicine (IM) residents. DESIGN: Qualitative analysis of CSR-based interviews with IM residents. PARTICIPANTS: Senior IM residents rotating on inpatient night float at the University of Pittsburgh Medical Center from February to September 2019. INTERVENTION: Each participant completed one, 20-min CSR session based on a self-selected case in which there was uncertainty in decision-making. Interviews explored the sources of, approaches to, and feelings about uncertainty. APPROACH: Two independent coders developed a codebook and independently coded all transcripts. Transcripts were then analyzed using thematic analysis. KEY RESULTS: The perceived acuity of the patient presentation was the main driver of the approach to and stress related to uncertainty. Perceived level of responsibility in resolving uncertainty during the overnight shift also varied among individual participants. Attending expression of uncertainty provided comfort to residents and alleviated stress related to uncertainty. Residents felt comfortable discussing their uncertainty and felt that the opportunity to think aloud during the exercise was valuable. CONCLUSIONS: Our study demonstrated a novel approach to the exploration of uncertainty in medical decision-making, with the use of CSR. Variations in resident perceived level of responsibility in resolving uncertainty during the overnight shift suggest a need for curriculum development in approach to uncertainty during night shifts. Though residents often experienced stress related to uncertainty, attending expression of uncertainty was an important mitigator of that stress, emphasizing the important role that the trainee-attending interaction plays in the diagnostic process.

Preparing Residents to Respond to Incidences of Gender Discrimination and Sexual Harassment: An Interactive Workshop.

OBJECTIVES: Gender discrimination and sexual harassment are common in academic medicine. There are limited data on how to prepare medical trainees to respond to these incidents. The objective of this work was to understand the experience of residents with sexual harassment and to evaluate the impact of a low-cost educational intervention to better prepare residents to respond to incidents of gender discrimination and sexual harassment. METHODS: We adapted a national faculty development workshop to be given to Internal Medicine residents. The workshop had three components: an introduction to the problem of sexual harassment, cases for guided practice, and review of Title IX. The workshop was presented to residents during protected academic time and assessed with pre-/post- surveys. RESULTS: The majority (65, 73.0%) of residents reported at least one incident of gender discrimination or sexual harassment in the prior 6 months; 62 (69.7%) residents reported an incident of gender harassment, 26 (29.6%) reported unwanted sexual attention, and 2 (2.3%) reported an incident of sexual coercion. The majority of residents (53, 62.4%) reported previous training, but only 28 (32.6%) felt well trained. Compared with before the workshop, residents reported more comfort (mean 2.88 vs 3.39, P = 0.0304) with and confidence (mean 3.47 vs 3.88, P = 0.0284) in responding to incidents of harassment. After the workshop, residents were more likely to use active responses, including express discomfort (15.0% vs 51.0%), express a preference (15.0% vs 53.1%), and debrief (13.3% vs 63.3%) and less likely to ignore the incident (56.7% vs 34.7%). CONCLUSIONS: This workshop offers one potential solution by better preparing residents to actively respond to incidents of gender discrimination and sexual harassment.

Best Practices for Survey Use in Medical Education: How to Design, Refine, and Administer High-Quality Surveys.

Surveys are a frequently used method to collect data in medical education research. As such, it behooves medical educators involved in scholarly work to understand the best practices in the selection, development, implementation, and reporting of surveys used when conducting research and curriculum development projects. This review article prepares the reader to name the steps of designing and administering high-quality surveys in medical education research, identify the characteristics of both well-written and poorly written survey questions, and apply the principles of survey design to write and revise surveys for use in their own research.

A 10-year experience of a novel and safe modified environmental rush immunotherapy protocol.

BACKGROUND: Allergen immunotherapy (AIT) is an effective treatment option for allergic rhinitis. Although conventional AIT takes 6 months to reach maintenance dosing, rush AIT accelerates the build-up period and reaches the maintenance dose months earlier. However, accelerated schedules of AIT carry an increased risk of systemic reactions (SR). OBJECTIVE: We aimed to describe a novel 1-day, eight-step modified environmental rush immunotherapy (MERIT) protocol, characteristics of the patients who underwent this therapy, and the safety of this procedure. We also compared distinguishing features of those patients with SRs. METHODS: We retrospectively analyzed demographic and clinical data of 362 adult patients seen in an outpatient university allergy clinic, from January 2005 to January 2015, and who underwent MERIT protocol treatment for allergic rhinitis. RESULTS: In a univariate analysis, the factors significantly associated with SR were lower body mass index (BMI); younger age; a higher number of allergens in the extracts; and the presence of cat, dust mite, and certain weed pollens. In a multivariate analysis, cat, dust mite, and mugwort were significantly associated with SRs. Over the 10-year period, 50 patients experienced SRs (13.81%), with a total number of 68 SRs. Only 4.7% of the SRs occurred on the MERIT day. Most SRs occurred >30 minutes and were mild. Our MERIT protocol continuation rate for all the patients was 49.2% and did not seem to be influenced by having an SR versus no SR. CONCLUSION: We present a modified rush AIT protocol that seems to be effective and safe. Most patients tolerated therapy, and only a minority of patients developed SRs, which generally were mild. We identified novel risk factors for SRs that may help determine optimal dosing to decrease the risk of SRs. Ultimately, future studies will be needed to compare the safety of our MERIT protocol with traditional AIT.

Update on Therapies and Treatments in Women's Health.

This article contains noninclusive language such as "females" and "women" when those terms were used in the research and historic context we are summarizing. New therapies have become available for vasomotor symptoms, postpartum depression, contraception, osteoporosis, recurrent yeast infections, acute and recurrent urinary tract infections, and female hypoactive sexual desire disorder. These therapies meet unique patient needs and change clinical practice for select groups. As is typical for new treatments, insurance coverage and access issues limit the adoption of some therapies.

Contraceptive Care in the Veterans Health Administration.

In recent years, the number of women Veterans obtaining care in the Veterans Affairs (VA) Healthcare System has grown, expanding the need for provision of contraceptive care. Women Veterans are a diverse group of women with complex sociodemographic and medical backgrounds, and meeting their needs presents a unique challenge for VA. Efforts including the establishment of comprehensive women's health clinics and training practitioners in women's health have greatly improved healthcare services for women Veterans over the last few decades. Recent data from a large cross-sectional survey study suggest that contraceptive use in VA is similar to the general population and that rates of unintended pregnancy, while still significant, are not higher than that in the general population. Subgroup analyses of this survey data, however, suggest that ongoing efforts are needed to improve outcomes in vulnerable subpopulations of women Veterans, particularly ethnic/racial minorities and Veterans with complex medical backgrounds. Policy changes such as the elimination of copayments for contraceptive prescriptions and the dispensing of more months of contraceptive supply are evidence-based starting points for improvements, in addition to leveraging VA's integrated system and research infrastructure to improve patient-centered counseling and contraceptive access.

Comparing the predictive ability of a commercial artificial intelligence early warning system with physician judgement for clinical deterioration in hospitalised general internal medicine patients: a prospective observational study.

OBJECTIVE: Our study compares physician judgement with an automated early warning system (EWS) for predicting clinical deterioration of hospitalised general internal medicine patients. DESIGN: Prospective observational study of clinical predictions made at the end of the daytime work-shift for an academic general internal medicine floor team compared with the risk assessment from an automated EWS collected at the same time. SETTING: Internal medicine teaching wards at a single tertiary care academic medical centre in the USA. PARTICIPANTS: Intern physicians working on the internal medicine wards and an automated EWS (Rothman Index by PeraHealth). OUTCOME: Clinical deterioration within 24 hours including cardiac or pulmonary arrest, rapid response team activation or unscheduled intensive care unit transfer. RESULTS: We collected predictions for 1874 patient days and saw 35 clinical deteriorations (1.9%). The area under the receiver operating curve (AUROC) for the EWS was 0.73 vs 0.70 for physicians (p=0.571). A linear regression model combining physician and EWS predictions had an AUROC of 0.75, outperforming physicians (p=0.016) and the EWS (p=0.05). CONCLUSIONS: There is no significant difference in the performance of the EWS and physicians in predicting clinical deterioration at 24 hours on an inpatient general medicine ward. A combined model outperformed either alone. The EWS and physicians identify partially overlapping sets of at-risk patients suggesting they rely on different cues or decision rules for their predictions. TRIAL REGISTRATION NUMBER: NCT02648828.

Peritoneal tuberculosis in an immunocompetent, unknown risk patient.

A 36-year-old man with no significant past medical history presented with two-month abdominal distention, night sweats, and weight loss of 15 Ib. He had no known exposure to tuberculosis. PPD test was negative prior to the hospital admission. Physical examination was notable for new onset ascites, but no superficial lymphadenopathy or stigmata of chronic liver disease was found. CT scan demonstrated enlarged mesenteric lymph nodes, and prominent retroperitoneal lymph nodes along with moderate ascites and omental infiltration. Diagnostic paracentesis yielded WBC of 295/mm(3), lymphocytic predominance (70%), and serum ascitic albumin gradient of 0.1, consistent with exudate. Both the ascitic culture and AFB smear were negative, and ascitic cytology revealed nonmalignant cells. Exploratory laparoscopy for excisional biopsy of mesenteric lymph nodes was performed. Pathologic findings revealed caseous granulomas with scattered multinucleated giant cells. Mesenteric lymph node tissue culture subsequently grew Mycobacterium tuberculosis complex and the diagnosis of peritoneal tuberculosis was confirmed. The patient was started on quadruple therapy. A couple of days after the antibiotics were started, the small bowel obstruction started to resolve with resumption of bowel movements and tolerance of oral intake. A week later, ascites stopped accumulating and fever was no longer noted. He has been well and continues to be under observation.