Workplace Violence: Experiences of Internal Medicine Trainees at an Academic Medical Center.

OBJECTIVES: Healthcare professionals are at higher risk for workplace violence (WPV) than workers in other sectors. This elevated risk exists despite the vast underreporting of WPV in the medical setting. The challenge of responding to this risk is compounded by limited empirical research on medical training environments. Understanding trainees' experience and educating them on workplace safety, WPV reporting, and awareness of resources are shared goals of educational and institutional leadership. In our setting, clear understanding and education were urgent after the enactment of a statewide "constitutional carry" law affording individuals a right to carry concealed firearms in all state-owned universities and hospitals, beginning in July 2017. We sought to examine the incidence of WPV affecting Internal Medicine trainees to understand the types of violence encountered, reporting rates, and the factors that influence reporting. METHODS: We conducted a cross-sectional online survey of Internal Medicine residents and fellows in practice for the previous 12 months. Survey items included both forced choice and open-ended questions. Descriptive statistics were calculated and used to summarize the study variables. χ2 tests were performed to examine whether sex differences existed for each of the survey questions. Qualitative responses were content analyzed and organized thematically. RESULTS: Of 186 trainees, 88 completed the survey. Forty-seven percent of respondents experienced WPV, with >90% of cases involving a patient, a patient's family member, or a patient's friend. Verbal assault was the most common type of incident encountered. Trainees formally reported fewer than half of the violent incidents disclosed in the survey. Major factors that influenced reporting included the severity of the incident, condition of the patient, and clarity of the reporting mechanism. CONCLUSIONS: Previous research indicates similar amounts and types of WPV. Likewise, a large percentage of the incidents are not reported. Addressing the key factors related to why physicians underreport can inform institutions on how to make systematic changes to reduce WPV and its negative impact. Future research is needed to examine whether specific interventions can be implemented to improve reporting and reduce the incidence of WPV.

Implementation of an Audience Response System in a Case Conference Curriculum: Results of a Placebo-Controlled Trial.

Audience response systems engage learners and facilitate the assimilation of the material. We assessed whether incorporation of one system into a resident case conference would increase retention of information and attentiveness. Pre-tests were administered prior to case conferences. The University Hospital incorporated Poll Everywhere into a conference and the Veterans Administration hospital did not. Participants rated self-perceived attentiveness and completed a post-test following conference. There was an increase in post-test scores compared to pre-tests. There was no significant difference in self-perceived attentiveness or post-test scores between sites. The use of audience response did not increase retention of material or perceived attentiveness when incorporated into the conference.

Reducing Resident Physician Workload to Improve Well Being.

Introduction Resident physician's well-being has been postulated to worsen with longer shifts. At our institution, the admitting physician evening shift (known as short call) had been associated with higher levels of stress and reduced well-being among residents due to longer work hours and an excessive number of admissions. We introduced an intermediate swing shift to help mitigate those effects. This study sought to assess the outcomes of introducing the swing shift on the timeliness of leaving the hospital for the short call physician, and the median number of admissions done by the short call, swing shift, and night shift resident physicians. Method  The swing shift was designed to cover admitting duties from 4:00 to 11:00 pm on weekdays, with support from both the short call and night shift resident physicians. Internal Medicine residents in their second or third year of training and combined Medicine/Psychiatry residents in their third, fourth or fifth year of training, were surveyed prior to the implementation of the swing shift and four-months post-implementation. Time of leaving the hospital and number of admissions before and after the introduction of the swing shift were compared. Data were recorded as frequencies and presented as medians. Results There were 27 surveys completed prior to swing shift implementation and 43 surveys completed post-implementation with a response rate of 52% and 83%, respectively. Surveys post-implementation were divided into 29 for the short call shift survey, six for the swing shift survey, and eight for the night shift survey. Residents who did not perform the short call physician duties were excluded, limiting the prior to implementation surveys from 27 to 25 and the post-implementation short call surveys from 29 to 19. Prior to swing shift implementation, the median time of leaving for the short call physician was 8:30 to 9:00 pm; the median number of admissions were four and eight, done by short call physician and night shift physician, respectively. Whereas post-swing shift implementation, the median time of leaving for short call physician was 7:00 to 7:30 pm, and for swing shift physician was 11:30 pm to midnight. The median number of admissions were two, five, and five done by the short call, swing shift, and night shift physicians, respectively. All residents reported the swing shift allowed them to take better care of patients and follow up on their tasks. Discussion and conclusion Delayed resident physicians departure at the end of their respective shift was associated with extended shifts. It is thought to be caused by an increased number of admissions, late shift admissions, and time of day shift with 4:00 to 9:00 pm being the busiest. The addition of the swing shift increased the ability of the short call resident physician to leave the hospital at the end of their shift and reduced the median number of admissions done by the short call and night shift resident physicians, hence likely improving resident's well-being while preserving the total number of admissions.

Severe cholestatic jaundice associated with Graves' disease.

We describe a rare case of Graves' disease presenting with atrial fibrillation and severe cholestasis. An extensive evaluation for hepatobiliary causes of cholestasis, including hepatic biopsy, was entirely negative. He was successfully treated with methimazole and eventual thyroidectomy. With caution, thionamides can be utilized successfully for such patients.