Impact of the COVID-19 Pandemic on Medical Education during Inpatient Internal Medicine Rounds.

OBJECTIVES: Inpatient rounding is a foundational component of medical education in academic hospitals. The coronavirus 2019 (COVID-19) pandemic disrupted traditional inpatient rounding practices. The objectives of this study were to describe how Internal Medicine inpatient team rounding changed because of COVID-19-related precautions and the effect of these changes on education during rounds. METHODS: During February to March 2021, we conducted four virtual focus groups with medical and physician assistant students, interns, upper-level residents, and attending physicians at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, and designed a codebook to categorize focus group commentary. RESULTS: Focus groups revealed that students believed that certain physical-distancing measures in place early on during the pandemic were ineffective and significantly limited their ability to evaluate patients in person. Residents described increased stress levels related to potential severe acute respiratory-coronavirus 2 exposure and limited time at the bedside, which affected their confidence with clinical assessments. Rounding-team fragmentation precluded the entire team learning from all of the patients on the team's census. Loss of intrateam camaraderie impaired the development of comfortable learning environments. CONCLUSIONS: This study evaluated Internal Medicine team member focus groups to describe how the COVID-19 pandemic affected medical education during rounds. Academic teaching programs can adapt the findings from this study to address and prevent pandemic-related gaps in medical education during rounds now and during future potential disruptions to medical education.

The Effect of Initial Patient Experiences and Life Stressors on Predicting Lost to Follow-Up in Patients New to an HIV Clinic.

We conducted a prospective cohort study of 450 patients new to an HIV clinic in Houston, TX, to examine the roles of life stressors and initial care experiences in predicting being lost to follow-up in the first year of care. Patients completed a self-administered survey following their initial provider visit. In logistic regression models, patients who reported better experiences with the HIV provider at the first visit were less likely to be lost to follow-up at 6 months (aOR = 0.866, p = 0.038) and 12 months (aOR = 0.825, p = 0.008). Patients with a higher burden of stressful life events were more likely to be lost to follow-up at 6 months (aOR = 1.232, p = 0.037) and 12 months (aOR = 1.263, p = 0.029). Assessments of patient experience and life stressors at the initial visit have potential to predict patients at risk of dropping out of care.

Acceptability and feasibility of video-based coaching to enhance clinicians' communication skills with patients.

BACKGROUND: Despite a growing call to train clinicians in interpersonal communication skills, communication training is either not offered or is minimally effective, if at all. A critical need exists to develop new ways of teaching communication skills that are effective and mindful of clinician time pressures. We propose a program that includes real-time observation and video-based coaching to teach clinician communication skills. In this study, we assess acceptability and feasibility of the program using clinician interviews and surveys. METHODS: The video-based coaching intervention targets five patient-centered communication behaviors. It uses trained communication coaches and live feed technology to provide coaching that is brief (less than 15 min), timely (same day) and theory-informed. Two coaches were trained to set up webcams and observe live video feeds of clinician visits in rooms nearby. As coaches watched and recorded the visit, they time stamped illustrative clips in real time. Video clips were a critical element of the program. During feedback sessions, coaches used video clips to promote discussion and self-reflection. They also used role play and guided practice techniques to enforce new tips. Clinicians included residents (n = 15), fellows (n = 4), attending physicians (n = 3), and a nurse practitioner (n = 1) at two primary care clinics in Houston, Texas. We administered surveys to clinicians participating in the program. The survey included questions on quality and delivery of feedback, and credibility of the coaches. We also interviewed clinicians following the intervention. We used rapid analysis to identify themes within the interviews. RESULTS: Survey measures showed high feasibility and acceptability ratings from clinicians, with mean item scores ranging from 6.4 to 6.8 out of 7 points. Qualitative analysis revealed that clinicians found that 1) coaches were credible and supportive, 2) feedback was useful, 3) video-clips allowed for self-reflection, 4) getting feedback on the same day was useful, and 5) use of real patients preferred over standardized patients. CONCLUSIONS: Video-based coaching can help clinicians learn new communication skills in a way that is clinician-centered, brief and timely. Our study demonstrates that real-time coaching using live feed and video technology is an acceptable and feasible way of teaching communication skills.

Acceptability and preferences for long-acting antiretroviral formulations among people with HIV infection.

The study evaluates the acceptability and preferences for long-acting antiretroviral therapy (LA-ART) among a diverse cohort of people with HIV infection (PWH). It consists of a self-administered survey and chart review of PWH presenting to an HIV clinic in Houston, Texas, between February and June 2018; 374 participants were included; 61% indicated that they were likely or very likely to use LA-ART formulations. When asked about preference, 41% preferred pills, 40% preferred injections, and 18% preferred an implant. The most common benefit reported was eliminating the need to remember taking daily HIV pills (74%); 43% were worried that LA-ART will not be as effective as pills. Participants with a college degree, men who have sex with men, and ART-experienced were more willing to use LA-ART. Participants who reported poor or fair health, or who screened positive for depression or anxiety were significantly less willing to use LA-ART. The likelihood of using LA-ART did not correlate with self-reported adherence and HIV suppression. Patients with difficulty scheduling and attending clinic visits preferred injections and implant over pills. Most participants indicated a willingness to use new LA ART formulations. However, 41% still prefers pills, and those more interested in LA-ART were not less adherent.

The psychology of the wait time experience - what clinics can do to manage the waiting experience for patients: a longitudinal, qualitative study.

BACKGROUND: Wait time, defined as time spent in the waiting and exam rooms waiting to see a provider, is a key quality metric in a number of national patient experience surveys. However, the literature on wait time does not show a consistent correlation between long waits and worse overall patient care experiences. Herein, we examine contextual factors that can shape the manner in which patients may respond to different wait times. We also identify actions providers and clinics can take to promote positive wait experiences and mitigate negative ones. METHODS: We conducted over 130 h of semi-structured interviews with patients new to two HIV primary care clinics in Houston, Texas. We interviewed patients before the first provider visit, again within two weeks of the first visit, and again at 6-12 months. We analyzed the interviews using directed and conventional content analysis. RESULTS: Our study showed that patients' "willingness to wait" is the product of the actual wait time, individual factors, such as the perceived value of the visit and cost of a long wait, and clinic and provider factors. Analyses revealed key steps providers and clinics can take to improve the wait time experience. These include: 1) proactively informing patients of delays, 2) explicitly apologizing for delays, and 3) providing opportunities for diversion. Patients noted the importance of these steps in curtailing frustrations that may result from a long wait. CONCLUSIONS: Our study highlights key steps cited by patients as having the potential to improve the wait time experience. These steps are practical and of particular interest to clinics, where waits are oftentimes inevitable.

Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study.

BACKGROUND: New patients are a particularly vulnerable population because they are at high risk of missing a subsequent visit or dropping out of care completely. However, few data exist on what new patients value in the beginning of a relationship with a new provider. Persons with HIV infection may be an ideal population to study the drivers of a positive initial patient-provider relationship, as it is a chronic and serious condition that requires a reliable, ongoing relationship with a provider. Informed by patients' real experiences, this study aims to identify what patients see as the most critical elements for building trust and rapport from the outset. METHODS: We conducted longitudinal, in-person interviews with 21 patients new to the HIV clinic at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, from August 2013 to March 2015. Patients were interviewed across three time points: once before their first provider visit, a second time within two weeks after the first visit, and a third time at 6 to 12 months after the first provider visit. RESULTS: We conducted 61 h of patient interviews. The mean age was 53 years; 52% were non-Hispanic white, 23% were non-Hispanic black and 19% were Hispanic. Patients described significant anxiety and vulnerability not just from HIV itself, but also in starting a relationship as a new patient to a new provider. Our analysis of these experiences revealed five actions providers can take to reduce their patients' anxiety and build trust early in the first visit: 1) provide reassurance to patients, 2) tell patients it's okay to ask questions, 3) show patients their lab results and explain what they mean, 4) avoid language and behaviors that are judgmental of patients, and 5) ask patients what they want [i.e., treatment goals and preferences]. CONCLUSIONS: Our study incorporates direct input from patients and highlights the unique psychological challenges that patients face in seeking care from a new provider. The actionable opportunities cited by patients have the potential to mitigate patients' feelings of anxiety and vulnerability, and thereby improve their overall health care experience.

Retaining HIV Patients in Care: The Role of Initial Patient Care Experiences.

Cross-sectional studies have shown an association between better patient experiences and health outcomes. However, the direction of causality remains unclear. Our prospective study seeks to determine whether better initial patient experiences predict subsequent retention in HIV care. We enrolled patients new to an HIV clinic in Houston, Texas, from August 26, 2013 to November 18, 2013. The patients' overall experience with the HIV provider was based on six items; overall experience with the HIV clinic was based on five items. We measured subsequent retention over the first 6 months and entire first year of HIV care. Analyses included 140 patients. Sixty-one percent were non-Hispanic black, 41 % were diagnosed with HIV within the last 3 months, and 36 % had a CD4 cell count <200. Thirty three percent were totally satisfied with their initial HIV provider experience and 32 % were totally satisfied with their initial HIV clinic experience. Retention was 68 % over the first 6 months and 51 % over the first year. Satisfaction with the HIV provider at the initial visit significantly predicted 6-month retention in care (aOR = 3.56, p = 0.006). Similar results were found for satisfaction with the HIV clinic (aOR = 4.67, p = 0.002). Neither of the patient experience measures at the initial visit predicted 12-month retention. Patients with better initial care experiences have significantly greater retention in HIV care. The effect of better initial care experiences was limited in duration. Consistently improving patient care experiences, not only at baseline but also on subsequent visits, may be a way to increase retention in HIV care.

Acceptability of a Future HIV Vaccine: A Rapid Scoping Review.

BACKGROUND: A HIV vaccine is not available yet, but perceptions of HIV vaccines will be important to explore before their roll-out for effective vaccine promotion. This article presents the findings of a rapid scoping review of the literature to identify individual, social, and vaccine-related factors associated with the acceptability of a future HIV vaccine. METHODS: We searched 5 databases (Medline OVID, Embase, PsycINFO, Web of Science, and Cochrane) using relevant keywords and Medical Subject Headings. All articles, regardless of study design, publication year, and geographic location, were included if they examined HIV vaccine acceptability and its underlying factors. RESULTS: We retrieved 2386 unique articles, of which 76 were included in the final review. Perceived benefits (34.2%) and perceived susceptibility (25.0%) were primary individual factors of HIV vaccine acceptability. Misinformation (17.1%) and distrust (22.4%) regarding future HIV vaccines, HIV stigma (30.3%), and social support (10.5%) were social factors of HIV vaccine acceptability. Vaccine efficacy (42.1%), cost (28.9%), and side effects (67.1%) were common vaccine characteristics influencing HIV vaccine acceptability. Altruism (10.5%) and risk compensation (26.3%) were also key factors. CONCLUSIONS: Our analyses revealed that skeptical beliefs, negative perceptions, and misconceptions about HIV vaccines are real barriers to their acceptability. To alleviate HIV vaccine hesitancy and address trust concerns, strategic vaccine communication should be disseminated by trustworthy sources. Messages should impart accurate vaccine information and emphasize both individual and social benefits of HIV vaccination, as well as leverage social support in increasing willingness to get a future HIV vaccine.

Survival outcomes in veterans with hepatocellular carcinoma, with and without HIV infection.

BACKGROUND: HIV infection has been associated with survival disparities among persons with hepatocellular carcinoma (HCC). However, most studies examining survival do not control for provider (e.g. type of HCC treatment given) or individual-level factors (e.g. homelessness, substance use) that could impact survival. In this study, we evaluate the effect of HIV status on survival among persons with HCC, in a comprehensive model that accounts for key individual, provider, and systems-level factors. METHODS: We conducted a retrospective cohort study of persons with HIV (PWH) matched 1 : 1 to HIV-negative controls based on age and year of HCC diagnosis in the national Veterans Administration (VA) health system. The primary outcome was survival. We used Cox regression models to evaluate the effect of HIV status on risk of death. RESULTS: This cohort included 200 matched pairs diagnosed with HCC between 2009 and 2016. A total of 114 PWH (57.0%) and 115 HIV-negative patients (57.5%) received guideline-concordant therapy ( P  = 0.92). Median survival was 13.4 months [95% confidence interval (CI) 8.7-18.1] among PWH and 19.1 months (95% CI 14.6-24.9) for HIV-negative patients. In adjusted models, older age, homelessness, advanced Barcelona Clinic Liver Cancer (BCLC) stage, and not receiving any HCC treatment predicted risk of death. HIV status was not associated with risk of death [adjusted hazard ratio (aHR) 0.95; 95% CI 0.75-1.20; P  = 0.65]. CONCLUSION: HIV status was not associated with worse survival among HCC patients, in a single-payer, equal access healthcare system. These results suggest that HIV infection alone should not exclude PWH from receiving standard therapy.

Attitudes and Beliefs of Patients With Left-Ventricular Assist Devices Toward COVID-19 Vaccination and Willingness to Seek Care During the Pandemic.

Given the stalling improvement in vaccine hesitancy rates in the United States (US), it is important to understand why a chronically ill group, patients with left-ventricular assist devices (LVADs), might not get vaccinated and to delineate the barriers they may face in seeking care. We conducted an online survey to characterize the attitudes of patients with LVADs toward COVID-19 vaccination, identify their willingness to seek care during the pandemic, and characterize barriers to doing so. Our survey showed that the rate of vaccine hesitancy among LVAD patients is similar to that of the general population in the US. This rate is higher than expected for a chronically ill group at risk of severe COVID-19 infection. We also found that LVAD patients perceive barriers to seeking care during the pandemic. We recommend that LVAD care teams emphasize that patients should seek care for emergency medical conditions despite their fears of contracting COVID-19. Based on our results, we also recommend vaccine uptake education for this population focused on patients' concerns about serious side effects and not enough research done on the vaccine.

Varicella reinfection in a seropositive physician following occupational exposure to localized zoster.

A 32-year-old physician with a history of chickenpox at age 5 and seropositivity to varicella-zoster virus (VZV) at age 30 developed fever and vesicular rash 14 days after examining an immunocompetent patient with localized herpes zoster ophthalmicus. Vesicular viral culture grew VZV, and the physician was diagnosed with VZV reinfection.

Patient-Reported Experiences with Dialysis Care and Provider Visit Frequency.

BACKGROUND AND OBJECTIVES: New payment models resulting from the Advancing American Kidney Health initiative may create incentives for nephrologists to focus less on face-to-face in-center hemodialysis visits. This study aimed to understand whether more frequent nephrology practitioner dialysis visits improved patient experience and could help inform future policy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In a cross-sectional study of patients receiving dialysis from April 1, 2015 through January 31, 2016, we linked patient records from a national kidney failure registry to patient experience data from the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems survey. We used a multivariable mixed effects linear regression model to examine the association between nephrology practitioner visit frequency and patient-reported experiences with nephrologist care. RESULTS: Among 5125 US dialysis facilities, 2981 (58%) had ≥30 In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems surveys completed between April 2015 and January 2016, and 243,324 patients receiving care within these facilities had Medicare Parts A/B coverage. Face-to-face practitioner visits per month were 71% with four or more visits, 17% with two to three visits, 4% with one visit, and 8% with no visits. Each 10% absolute greater proportion of patients seen by their nephrology practitioner(s) four or more times per month was associated with a modestly but statistically significant lower score of patient experience with nephrologist care by -0.3 points (95% confidence interval, -0.5 to -0.1) and no effect on experience with other domains of dialysis care. CONCLUSIONS: In an analysis of patient experiences at the dialysis facility level, frequent nephrology practitioner visits to facilities where patients undergo outpatient hemodialysis were not associated with better patient experiences.

Patients' Experiences with Refilling their HIV Medicines: Facilitators and Barriers to On-Time Refills.

BACKGROUND: Adherence to antiretroviral therapy (ART) is particularly important for patients with HIV. Prior research on ART adherence has focused primarily on behavioral interventions targeting patients and providers. No study has focused on the pharmacy refill experience as a potential target for improving adherence to HIV medicines. Informed by patients' experiences, this study aimed to assess patients' experiences with refilling their HIV medicines and to explore facilitators and barriers to refilling medicines on time. METHODS: We interviewed patients at three time points during their first year of care at an HIV clinic in Houston, TX. We analyzed interviews using directed and conventional content analysis. RESULTS: Analyses revealed individual, interpersonal, and system-level barriers that affect patients' ability to pick up their HIV medicines on time. Many patients perceived the refill process as being difficult. For some patients, picking up their HIV medicines each month triggered anxiety. Positive interactions with pharmacists and pharmacy staff, as well as clear and consistent messaging, played a key role in augmenting patients' refill experience. Self-efficacy, social support, and workarounds to resolve issues were also key facilitators. Many patients said changing ART-dispensing protocols from 30- to 90-day refills could mitigate the anxiety experienced with picking up HIV medicines and decrease opportunities for missing a refill. CONCLUSION: Offering 90-day refills for HIV medicines may decrease anxiety concerning missed doses and improve medication adherence. Providing pharmacy staff with communication skills training is another strategy that may improve the patients' refill experience.

Exploring the Attitude of Patients with HIV About Using Telehealth for HIV Care.

Telehealth could address many of the factors identified as barriers for retention in HIV care. In this study, we explore people with HIV (PWH)'s attitudes about using telemedicine for HIV care instead of face-to-face clinic visits. We administered a one-time survey to PWH presenting to an outpatient HIV center in Houston, Texas, from February to June 2018. The survey items were used to assess PWH's attitudes toward and concerns for telehealth and explanatory variables; 371 participants completed the survey; median age was 51, 36% and were female, and 63% was African American. Overall 57% of respondents were more likely to use telehealth for their HIV care if available, as compared with one-on-one in-person care, and 37% would use telehealth frequently or always as an alternative to clinic visits. Participants reported many benefits, including ability to fit better their schedule, decreasing travel time, and privacy but expressed concerns about the ability to effective communication and examination and the safety of personal information. Factors associated with likelihood of using telehealth include personal factors (US-born, men who have sex with men, higher educational attainment, higher HIV-related stigma perception), HIV-related factors (long-standing HIV), and structural factors (having difficulty attending clinic visits, not knowing about or not having the necessary technology). There was no association between participants with uncontrolled HIV, medication adherence, and likelihood of using telehealth. Telehealth programs for PWH can improve retention in care. Availability and confidence using various telehealth technologies need to be addressed to increase acceptability and usage of telehealth among PWH.

What patient involvement means to new patients at two HIV clinics: A longitudinal, qualitative study.

OBJECTIVES: This study 1) defines patient involvement from the perspective of patients new to a provider, 2) describes provider communication that patients perceive as promoting involvement, and 3) examines changes in patient definitions of involvement over time. METHODS: We enrolled 56 patients at two HIV clinics in Houston, Texas, from August 2013 until March 2015. We interviewed patients three times during the first year of care and analyzed interviews using content analysis. RESULTS: The mean age was 45 years; 54% were men. Patient definitions of involvement ranged from adherence- to decision-oriented. Analysis revealed three provider communication behaviors that patients perceive as promoting involvement: 1) soliciting patient feedback, 2) discussing treatment options and trade-offs, 3) narrating the decision-making process. Definitions of involvement can change over time as providers reframe the patient's illness as manageable and through perceived partnerships with the provider. CONCLUSION: Provider communication plays a critical role in shaping new patients' perception of involvement and can make patients feel involved even when patients do not actively make medical decisions. PRACTICAL IMPLICATIONS: Finding strategies to make patients feel involved in their care is important, particularly for new patients, even if those strategies do not necessarily promote more talk from the patient.

Knowledge of HIV Testing Guidelines Among US Internal Medicine Residents: A Decade After the Centers for Disease Control and Prevention's Routine HIV Testing Recommendations.

Ten years after the Centers for Disease Control and Prevention recommended universal HIV screening, rates remain low. Internal medicine residents are the front-line medical providers for large groups of patients. We evaluated the knowledge of internal medicine residents about HIV testing guidelines and examined adherence to universal HIV testing in an outpatient setting. A cross-sectional survey of internal medicine residents at four residency programs in Chicago was conducted from January to March 2016. Aggregate data on HIV screening were collected from 35 federally qualified community health centers in the Chicago area after inclusion of an HIV testing best practice alert in patients' electronic medical records. Of the 192 residents surveyed, 130 (68%) completed the survey. Only 58% were aware of universal HIV screening and 49% were aware that Illinois law allows for an opt-out HIV testing strategy. Most of the residents (64%) ordered no more than 10 HIV tests in 6 months. The most frequently reported barriers to HIV testing were deferral because of urgent care issues, lack of time, and the perception that patients were uncomfortable discussing HIV testing. From July 2015 to February 2016, the average HIV testing adherence rate in the 35 health centers was 18.2%. More effort is needed to change HIV testing practices among internal medicine residents so that they will adopt this approach in their future clinical practice. Improving knowledge about HIV testing and addressing other HIV testing barriers are essential for such a successful change.

Assessing residents' knowledge of patient satisfaction: a cross-sectional study at a large academic medical centre.

OBJECTIVES: Patient satisfaction impacts healthcare quality and outcomes. Residents play an important role in patient satisfaction at academic institutions. This study aims to assess residents' patient satisfaction knowledge and determine which learning experiences contributed to their knowledge acquisition. SETTINGS: This study was conducted at a health science university in a large, urban, tertiary-care academic medical centre in the USA. PARTICIPANTS: All residents from internal medicine (n=185) and paediatrics (n=156) were asked to participate. DESIGN: Residents completed a survey from April 2013 to December 2013 that assessed (1) knowledge of factors that impact patient satisfaction and (2) learning experiences that may have contributed to their understanding of the drivers of patient satisfaction (eg, experiential (personal or clinical) or didactics). Trainees identified the importance of factors in determining patient satisfaction on a five-point Likert scale; answers were compiled into a knowledge score. The score was correlated with prior personal/clinical experience and didactics. RESULTS: Of the 341 residents, 247 (72%) completed the survey. No difference was found in knowledge among training levels or residency programme. More than 50% incorrectly thought physician board certification, patient's education, patient's income and physician's age impacted satisfaction. Personal experience, through hospitalisation of a relative or friend, was correlated with higher knowledge (67% vs 71%, p=0.03). Ninety-nine per cent (n=238) stated peer observation, and all stated faculty feedback impacted their patient satisfaction knowledge. Seventy-seven per cent (n=185) had attended didactics on satisfaction, but attendance did not correlate with higher scores. CONCLUSIONS: Our study showed trainees have a few gaps in their patient satisfaction knowledge, and attending past educational sessions on patient satisfaction did not correlate with higher knowledge scores. Our data suggest that academic centres should leverage residents' personal experiences, their observations of peers and faculty feedback to enhance patient satisfaction knowledge.

Veterans' Perspectives on Interventions to Improve Retention in HIV Care.

Poor retention in HIV medical care is associated with increased mortality among patients with HIV/AIDS. Developing new interventions to improve retention in HIV primary care is needed. The Department of Veteran Affairs (VA) is the largest single provider of HIV care in the US. We sought to understand what veterans would want in an intervention to improve retention in VA HIV care. We conducted 18 one-on-one interviews and 15 outpatient focus groups with 46 patients living with HIV infection from the Michael E. DeBakey VAMC (MEDVAMC). Analysis identified three focus areas for improving retention in care: developing an HIV friendly clinic environment, providing mental health and substance use treatment concurrent with HIV care and encouraging peer support from other Veterans with HIV.