Intentions of Kentucky School Nurses to Delegate Diabetes-Related Tasks to Unlicensed Assistive Personnel.

Many children have diagnosed diabetes that must be safely managed at school. New laws have created the potential for school systems to rely more heavily on unlicensed assistive personnel (UAP) than on nurses to deliver health services, including administration of insulin injections. Using the theory of planned behavior as a framework, aims were to (1) determine the nature and extent to which health services related to diabetes were being delegated to UAP in Kentucky schools, (2) describe the attitudes of Kentucky school nurses regarding the delegation of diabetes health services to UAP, and (3) examine the relationship of selected variables to school nurses' intentions to delegate diabetes health services. Survey results revealed that school nurses in Kentucky intended to delegate some diabetes-related tasks despite their lack of support for delegation of those tasks.

Twelve-month employment intervention outcomes for drug-involved offenders.

BACKGROUND: Employment has been identified as an important part of substance abuse treatment and is a predictor of treatment retention, treatment completion, and decreased relapse. Although employment interventions have been designed for substance abusers, few interventions have focused specifically on drug-involved offenders. OBJECTIVES: The purpose of this study was to examine employment outcomes for drug-involved offenders who received a tailored employment intervention. METHODS: In a randomized controlled trial, baseline and follow-up data were collected from 500 drug-involved offenders who were enrolled in a drug court program. Participants were randomly assigned to drug court as usual (control group) or to the employment intervention in addition to drug court. RESULTS: Intent-to-treat analyses found that the tailored intervention was associated only with more days of paid employment at follow-up (210.1 vs. 199.9 days). When focusing on those with greater employment assistance needs, a work trajectory analyses, which took into account participants' pre-baseline employment pattern (negative or positive), revealed that intervention group participants had higher rates of employment (82.1% vs. 64.1%), more days paid for employment (188.9 vs. 157.0 days), and more employment income ($8623 vs. $6888) at follow-up than control group participants. CONCLUSION: The present study adds to the growing substance abuse and employment literature. It demonstrates the efficacy of an innovative employment intervention tailored for drug-involved offenders by showing positive changes in 12-month employment outcomes, most strongly for those who have not had recent employment success.

Are primary care providers uncomfortable providing routine preventive care for inflammatory bowel disease patients?

BACKGROUND AND AIMS: Those with chronic diseases, including inflammatory bowel disease (IBD), often do not receive preventive care at the same rate as the general population. Attitudes of primary care providers could be key factors in the receipt of preventive care. METHODS: We surveyed attendees of a family medicine review course. The survey contained nine demographic items, four items to assess exposure to and comfort level with IBD, and six clinical vignettes. RESULTS: Of surveys, 36% (61/169) were returned. The large majority were males practicing outpatient family medicine. Mean age was 51 years, and 48% reported a mostly rural practice. Of subjects, 10% reported either having IBD themselves or having a close associate or relative with IBD. Only 37% of subjects felt comfortable providing primary care across a range of illness severity. Forty-six percent reported moderate or high exposure to IBD. For the case vignettes, the overall highest rate of endorsement of the active role was 84% for a case related to stage I hypertension, while the lowest rate was 30% for an item relating to vaccination for immunosuppressed persons. We assessed the following predictors of comfort level and active role responses and found no significant associations: age, gender, years of medical practice, and close contact with IBD. CONCLUSIONS: Our study suggests that family medicine practitioners often do not feel comfortable providing care to IBD patients. Lack of familiarity with IBD medications may be a key factor.

Is time spent with the physician associated with parent dissatisfaction due to long waiting times?

The objectives of this study were to assess the relationship between wait time and parent satisfaction and determine whether time with the physician potentially moderated any observed negative effects of long wait time. Data were collected from parents in a pediatric outpatient clinic. Parent satisfaction with the clinic visit was significantly negatively related to wait times. More time spent with the physician was positively related to satisfaction independent of wait times. Furthermore, among clinic visits with long wait times, more time with the physician showed a relatively strong positive relationship with parent satisfaction. Therefore, although long wait times was related to decreased parent satisfaction with pediatric clinic visits, increased time with the physician tended to moderate this relationship.

A complementary and alternative medicine workshop using standardized patients improves knowledge and clinical skills of medical students.

OBJECTIVES: As the use of complementary and alternative medicine (CAM) has increased in the general population, so has the interest in CAM education among medical students and medical educators. The purpose of this study is to determine the impact of a CAM workshop using standardized patients (SP) on knowledge and clinical skills of third-year medical students. DESIGN: A 4-hour CAM workshop was developed as part of a new curriculum for a required third-year 4-week primary care internal medicine clerkship. The CAM workshop and 3 other novel workshops were randomized for delivery to half of the rotational groups. The CAM workshop incorporates 4 SP cases representing different clinical challenges. All students in every rotation group are assigned CAM readings. At the end of the rotation, all students take a 100-item written exam (7 CAM items) and 9-station SP exam (1 CAM station) including a post-SP encounter open-ended written exercise. Scores on the written exam CAM items, CAM SP checklist, and CAM open-ended written exercise of workshop participants and nonparticipants were analyzed with simple means, standard deviations, and multiple regression approaches. RESULTS: The CAM workshop was delivered to 12 of the 24 rotation groups during the 2004-2005 and 2005-2006 academic years. Ninety-two students participated in the workshop, and 94 did not. Workshop participants performed significantly better than nonparticipants on the CAM-specific SP checklist items (58 vs 36.6%, P<.0001), post-SP encounter written exercise (76.9 vs 63.3%, P<.0001), and 7 CAM written exam items (84.8 vs 76.3%, P<.0001). CONCLUSIONS: Students participating in a 4-hour SP workshop exhibit superior CAM knowledge as assessed by SP checklist, open-ended exercises, and multiple choice items. It appears that practice with SPs assists in acqusition and application of CAM knowledge and deferential counseling skills.

Internal medicine clerkship characteristics associated with enhanced student examination performance.

PURPOSE: To determine which internal medicine (IM) clerkship characteristics are associated with better student examination performance. METHOD: The authors collected data from 17 U.S. medical schools (1,817 students) regarding characteristics of their IM clerkships, including structural characteristics, pedagogical approaches, patient contact, and clinical teacher characteristics. Outcomes of interest were postclerkship National Board of Medical Examiners (NBME) subject examination score, United States Medical Licensing Examination (USMLE) 2 score, and change in score from USMLE 1 to 2. To examine how associations of various clerkship characteristics and examination performance may differ for students of different prior achievement, the authors categorized students into those who scored in the top (1/4) of the cohort on USMLE 1 and the bottom (1/4). The authors conducted analyses at both the school and the individual student levels. RESULTS: In school-level analyses (using a reduced four-variable model), independent variables associated with higher NBME subject examination score were more small-group hours/week and use of community-based preceptors. Greater score increase from USMLE 1 to 2 was associated with students caring for more patients/day. Several variables were associated with enhanced student examination performance at the student level. The most consistent finding was that more patients cared for per day was associated with higher examination performance. More structured learning activities were associated with higher examination scores for students with lower baseline USMLE 1 achievement. CONCLUSION: Certain clerkship characteristics are associated with better student examination performance, the most salient being caring for more patients per day.

Enhancing knowledge and clinical skills through an adolescent medicine workshop.

OBJECTIVE: To determine the effect of a medical school adolescent medicine workshop on knowledge and clinical skills using standardized patients. DESIGN: Randomized controlled trial. SETTING: The University of Kentucky College of Medicine, Lexington. PARTICIPANTS: A total of 186 third-year medical students. Intervention Medical students assigned to the intervention group (n = 95) participated in a 4-hour adolescent medicine workshop using standardized patients to practice interviewing and counseling skills. Medical students assigned to the control group (n = 91) participated in an alternative workshop. OUTCOME MEASURES: Medical student adolescent interviewing and counseling skills were assessed using adolescent standardized patient encounters during the end-of-clerkship examination and during the end of the third-year Clinical Performance Examination. Medical student knowledge was assessed at the end of the clerkship using an open-ended postencounter written exercise and the questions specific to adolescent medicine on the clerkship written examination. RESULTS: Both groups had comparable baseline characteristics. Medical students in the intervention group scored significantly higher on both measures of clinical skills, the standardized patient stations during the end-of-clerkship examination and the Clinical Performance Examination. Intervention medical students also scored significantly higher on both measures of knowledge, the open-ended postencounter written exercise and the written examination. CONCLUSIONS: A brief adolescent medicine workshop using standardized patients improved medical students' knowledge and skills at the end of a 4-week clerkship, and the improvement in clinical skills persisted at the end of the third year of medical school.

Changes in internal medicine residents' attitudes about resuscitation after cardiac arrest over a decade.

BACKGROUND: Resident physicians' beliefs about cardiopulmonary resuscitation (CPR) may impact their communication with patients about end-of-life care. We sought to understand how these perceptions and experiences have changed in the past decade because both medical education and American society have focused more on this domain. METHOD: We surveyed 2 internal medicine resident cohorts at a large academic medical center in 1995 and 2005. Residents were asked of their beliefs about survival after CPR, perceived patient understanding, and regret after attempted resuscitation. Residents in 2005 reported more numerical experience with CPR. Current internal medicine residents are more optimistic than the 1995 cohort about survival after an inpatient cardiac arrest. They believe that far fewer patients and families understand resuscitation but report less regret about attempting to resuscitate patients. CONCLUSIONS: These pilot data reveal potential changes in the attitudes of resident physicians toward CPR. The perceived poor understanding among decision makers calls into question the standard of informed consent. Despite this, residents report less regret leading one to ask what factors may underlie this response.

Attitudes of Kentucky women regarding mandatory reporting of intimate partner violence.

BACKGROUND: Kentucky is one of only six states with laws mandating that intimate partner violence be reported to authorities. The purpose of this project was to understand the attitudes of women clinic patients in Kentucky regarding mandatory reporting of intimate partner violence and how these attitudes may differ by abuse status. METHODS: Women presenting to an internal medicine clinic in the summer of 2003 were asked to complete an anonymous 30-item questionnaire, including personal history of abuse and their opinions about mandatory reporting of intimate partner violence to the police. RESULTS: Surveys were completed by 238 women, of which 29% reported a history of intimate partner violence. Of abused women, 49% supported mandatory reporting of intimate partner violence to the police, compared to 61% of women without an abuse history (p = 0.05) CONCLUSION: Women with a history of abuse are more ambivalent about mandatory reporting of intimate partner violence to the police than women without a history of abuse.

Communication and decision making about life-sustaining treatment: examining the experiences of resident physicians and seriously-ill hospitalized patients.

BACKGROUND: Despite evidence-based recommendations for communication and decision making about life-sustaining treatment, resident physicians' actual practice may vary. Few prior studies have examined these conversations qualitatively to uncover why ineffective communication styles may persist. OBJECTIVE: To explore how discussions about life-sustaining treatment occur and examine the factors that influence physicians' communicative practices in hopes of providing novel insight into how these processes can be improved. PARTICIPANTS AND APPROACH: We conducted and recorded 56 qualitative semi-structured interviews with participants from 28 matched dyads of a resident physician and a hospitalized patient or their surrogate decision maker with whom cardiopulmonary resuscitation was discussed. Transcripts were analyzed and coded using the constant comparative method to develop themes. MAIN RESULTS: Resident physicians introduced decisions about resuscitation in a scripted, depersonalized and procedure-focused manner. Decision makers exhibited a poor understanding of the decision they were being asked to make and resident physicians often disagreed with the decision. Residents did not advocate for a particular course of action; however, the discussions of resuscitation were framed in ways that may have implicitly influenced decision making. CONCLUSIONS: Residents' communication practices may stem from their attempt to balance an informed choice model of decision making with their interest in providing appropriate care for the patient. Physicians' beliefs about mandatory autonomy may be an impediment to improving communication about patients' choices for life-sustaining treatment. Redefining the role of the physician will be necessary if a shared decision making model is to be adopted.

The effect of physician continuity on diabetic outcomes in a resident continuity clinic.

BACKGROUND: Conflicting data exists regarding the effect of continuity on diabetes care. Resident physicians frequently treat patients with diabetes in their continuity clinics; however, maintaining continuity in a resident clinic can be very challenging. OBJECTIVE: To determine if resident continuity is associated with improvement in diabetic outcomes (HgA1c, LDL, blood pressure) in a resident clinic. DESIGN AND SETTING: Retrospective analysis of data obtained from a medical record review of diabetic patients seen in a resident physician clinic. MEASUREMENTS: We measured continuity, using the Usual Provider of Continuity Index (UPC) for residents and faculty preceptors. We measured changes in HgA1c, LDL, and blood pressure over a 3-year period. Using repeated measures analysis of variance (ANOVA), we assessed the relationship between UPC and change in these diabetic outcomes. RESULTS: The resident UPC was 0.43, and the faculty preceptor UPC was 0.76. The overall change in HgA1c was -0.3. There was a statistically significant relationship between improvement in HgA1c and resident UPC (p = 0.02), but not faculty preceptor UPC. There was no association between resident or faculty preceptor continuity and change in LDL or blood pressure. CONCLUSION: This study showed a link between resident continuity and improvement in glycemic control in diabetic patients. Resident physicians have a greater opportunity to develop a personal relationship with their patients. This interpersonal continuity may be of benefit in patients with illnesses that requires a significant amount of self-management behaviors. Medical training programs should focus efforts on improving continuity in resident primary care clinics.

The association of student examination performance with faculty and resident ratings using a modified RIME process.

BACKGROUND: RIME is a descriptive framework in which students and their teachers can gauge progress throughout a clerkship from R (reporter) to I (interpreter) to M (manager) to E (educator). RIME, as described in the literature, is complemented by residents and attending physicians meeting with a clerkship director to discuss individual student progress, with group discussion resulting in assignment of a RIME stage. OBJECTIVE: 1) to determine whether a student's RIME rating is associated with end-of-clerkship examination performance; and 2) to determine whose independent RIME rating is most predictive of a student's examination performance: attendings, residents, or interns. DESIGN: Prospective cohort study. PARTICIPANTS: Third year medical students from academic years 2004-2005 and early 2005-2006 at 1 medical school. MEASUREMENTS AND MAIN RESULTS: Each attending, resident, and intern independently assessed the student's final RIME stage attained. For the purpose of analysis, R stage=1, I=2, M=3, and E=4. Regression analyses were performed with examination scores as dependent variables (National Board of Medical Examiners [NBME] medicine subject examination and a clinical performance examination [CPE]), with independent variables of mean attending RIME score, mean resident score, and mean intern score. For the 122 students, significant predictors of NBME subject exam score were resident RIME rating (p = .008) and intern RIME rating (p = .02). Significant predictor of CPE performance was resident RIME rating (p = .01). CONCLUSION: House staff RIME ratings of students are associated with student performance on written and clinical skills examinations.

End-of-life care in adults with cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is a life-limiting congenital disease, with most patients dying at a young age of progressive lung disease. Lung transplantation offers hope for many but may not occur. There is little to guide the provision of palliative care to this young population who maintain hope in the possibility of lung transplantation. METHODS: To inform the development of an appropriate model of palliative care, a medical record review of CF patients dying within a 5-year period without lung transplantation was undertaken. The aspects of care that were preventative, therapeutic, or palliative were quantified. RESULTS: Of the 20 records studied, all died in hospital. Only 15% of patients had a do-not-resuscitate order agreed to more than 1 week prior to death, increasing to 90% at the time of death (median of 2 days before death). Opioids were prescribed for 1 patient (5%) at 1 week prior to death, increasing to 85% of patients in the last 24 hours of life (median of 36 hours before death). During the last 24 hours of life, intravenous antibiotics continued in 85%, and assisted ventilation in 90% of subjects. CONCLUSION: We conclude that the circumstances surrounding the death of patients with CF holds challenges for their effective palliative care. CF patients continue life prolonging and preventative treatments until the last hours of life. There is an urgent need to examine palliative care approaches that may usefully coexist with maintaining transplantation options in the end-of-life care of this population.

Discussing preferences for cardiopulmonary resuscitation: what do resident physicians and their hospitalized patients think was decided?

OBJECTIVE: To explore the ways in which seriously ill hospitalized patients, their family members and physicians interpret the discussion of the patient's preferences for cardiopulmonary resuscitation (CPR). METHODS: Resident physicians, their patients, and family members were interviewed following a discussion regarding preferences for CPR. We sought the participants' perceptions of the resulting decision, examined how often these interpretations differed, and explored the communicative factors underlying discrepancies when they occurred. RESULTS: Fifty-six interviews with 28 matched dyads were completed. In six dyads (21%), the participants reported differing results of the discussion. Two patients had orders to limit their care based on the physician's interpretation of their discussion. Another two patients who did not want resuscitation lacked a DNR order. Two patients did not recall having the conversation. These discrepancies could be attributed to the physician misconstruing the patient's wishes, interference of a family member, and fluctuating preferences. CONCLUSIONS: Discrepant interpretations of a DNR discussion occur with a concerning frequency between resident physicians and their hospitalized patients. PRACTICE IMPLICATIONS: Educational efforts should focus on training physicians to clarify the language used in these discussions, remain vigilant about discerning the patient's preferences, and be aware that these preferences may be contextually fluid.

Sexual history inquiry and HIV counseling: improving clinical skills and medical knowledge through an interactive workshop utilizing standardized patients.

BACKGROUND: Sexual history and HIV counseling (SHHIVC) are essential clinical skills. Our project's purpose was to evaluate a standardized patient educational intervention teaching third-year medical students SHHIVC. METHODS: A four-hour standardized patient workshop was delivered to one-half of the class each of three consecutive years at one medical school. Approximately 3.5 weeks later, all students engaged in a standardized patient examination including one station assessing SHHIVC, answered an open-ended written exercise following the standardized patient encounter, and completed a written examination including sexual history and HIV-related questions. RESULTS: Workshop participants scored higher than non-participants on SHHIVC items on the standardized patient station (P < .0001), written exam (P < .0001), and open-ended written exercise after the standardized patient encounter (P = .024). CONCLUSIONS: Our SHHIVC curriculum was associated with students demonstrating better clinical skills on a SHHIVC standardized patient examination station and more SHHIVC knowledge on two measures of medical knowledge than students not participating in the SHHIVC educational intervention.

Student involvement on teaching rounds.

BACKGROUND: Inpatient internal medicine education occurs in a fragile learning environment. The authors hypothesized that when medical students are involved in teaching rounds, residents may perceive a decrease in value of attending teaching. METHOD: During two summer periods, trained research assistants shadowed teaching rounds, tracking patient census and team call status, recording basic content of rounds, and delivering a survey instrument to the learners, asking them to rate the quality of the attending's teaching that day. RESULTS: One hundred sixty-six rounds were analyzed. Attending teaching ratings peaked when students were highly involved. In fact, high student involvement was an independent predictor of higher resident evaluation of teaching rounds (P < .0001). CONCLUSIONS: The best teaching occurred when involvement of medical students was greatest and their involvement was not necessarily a zero-sum game. The authors conclude that attending investment in medical student education during teaching rounds benefits all members of the inpatient team.

A randomized controlled trial using insinuated standardized patients to assess residents' domestic violence skills following a two-hour workshop.

BACKGROUND: Residents feel inadequately trained to treat domestic violence victims. PURPOSE: The purpose was to assess clinical skills of residents participating in a domestic violence workshop. METHODS: Twenty-seven internal medicine residents were randomized to receive one of two workshops (domestic violence or control workshop). Standardized patients were trained to two domestic violence cases (depressed; injured). The two cases were randomized and insinuated into each resident's continuity clinic at either 1 to 3 months or more than 3 months after the workshops. RESULTS: The domestic violence workshop residents did not identify the standardized patients as domestic violence victims any more often than residents participating in the control workshop; 16/25 (64%) versus 13/23 (56%), p=.86. However, domestic violence workshop residents were more likely to score 75% or higher on the domestic violence checklist items compared to control workshop residents; 9/25 (36%) versus 2/23 (9%), p=.04. CONCLUSIONS: Once a standardized patient was identified in clinic as a domestic violence victim, domestic violence workshop participating residents demonstrated better clinical skills than a control group.

Do pressure and fatigue influence resident job performance?

BACKGROUND: Global surveys of residents have consistently identified stress variables as important factors in resident job performance. AIMS: Determine whether an association exists between resident stress and job performance. METHOD: Over a three month period, interns on our inpatient ward services were surveyed regarding their current call schedule, whether their prior night's sleep was sufficient, whether they felt pressed by other commitments, whether they spent enough time teaching medical students and whether they had completed all patient care issues on a given day. Multiple logistic regression was used to assess the association between call status, pressure and sleep adequacy with reported omissions in patient care and adequacy of teaching. RESULTS: In the regression analysis, ratings of high pressure and insufficient sleep but not call status independently predicted outcomes. For example, if an intern felt both pressed and tired, they were over eight times more likely to omit a patient care issue and over four times more likely to report inadequate teaching. CONCLUSIONS: Subjective ratings of high pressure and insufficient sleep are associated with poor job performance in medical residents.

Medical residents' perspectives on discussions of advanced directives: can prior experience affect how they approach patients?

INTRODUCTION: Resident physicians are inadequately taught how to communicate with patients about end-of-life decision making. Their beliefs about resuscitation and prior experiences with end-of-life care may impact the manner in which they approach patients. OBJECTIVE: To explore residents' perceptions of end-of-life discussions, determine the features they find most important, and discern the challenges they face in this process. METHODS: Internal medicine residents were surveyed about their experiences discussing resuscitation with patients including perceptions of patient understanding, outcomes of resuscitation, and regret about attempting to resuscitate patients. They were asked what features of these discussions are most important and which are the most challenging. Qualitative content analysis was used to examine the responses to open-ended questions. RESULTS: Fifty-five residents completed the survey. Residents reported rarely feeling satisfied with the results of these discussions and disagreed with the decision for resuscitation numerous times. They perceive that few patients and families understand resuscitation. In their description of important features, they focus on the content of the discussion rather than the process, with the most common responses centering on a description of resuscitation. In contrast, the greatest challenge they identify is dealing with the emotional aspects of the discussion. CONCLUSIONS: Residents report internal conflict about their experiences discussing resuscitation with patients. Their approach to these discussions focuses on resuscitation itself with less attention paid to processes that might improve patient decision making. The challenges they describe may be overcome with improved education about end-of-life communication.

The relationship between experience with standardized patient examinations and subsequent standardized patient examination performance: a potential problem with standardized patient exam validity.

Standardized patient (SP) exams are becoming an important part of testing clinical skills. The dynamics of this test format warrant exploration. This study is designed to measure the relationship between experience with SPs and performance on a SP examination. A general linear model is used to determine if a relationship exists and the pattern of that relationship as experience increases. There is a linear association between increased experience and better performance in technical domains. In interpersonal skill domains, there is a curvilinear association between experience and performance with improved performance with moderate levels of experience but not in the most experienced group. Different levels of experience with SPs are associated with differences in performance. The varied pattern of associations suggests a possible practice effect or test-taking behavior. Additional studies are needed to assess this potential effect on SP exam validity.