A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication.

BACKGROUND: Patient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient-physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction. OBJECTIVE: To determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers. DESIGN: Internal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective pre-post comparisons. PARTICIPANTS: Twenty-two internal medicine residents in their second or third postgraduate year. INTERVENTION: An educational dinner describing the format and potential benefits of using the CPI. MAIN MEASURES: Retrospective pre-post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians. KEY RESULTS: All night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups. CONCLUSIONS: Resident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician-physician communication. These results suggest that the method should be taught and implemented more frequently.

Emergency manual implementation: can brief simulation-based or staff trainings increase familiarity and planned clinical use?

BACKGROUND: Emergency manuals (EMs)-context-relevant sets of cognitive aids such as crisis checklists-are useful tools to enhance perioperative patient care. Studies in high-hazard industries demonstrate that humans, regardless of expertise, do not optimally retrieve or deploy key knowledge under stress. EM use has been shown in both health care simulation studies and other industries to help expert teams effectively manage critical events. However, clinical adoption and use are still nascent in health care. Recognizing that training with, access to, and cultural acceptance of EMs can be vital elements for successful implementation, this study assessed the impact of a brief in situ operating room (OR) staff training program on familiarity with EMs and intention to use them during critical events. METHODS: Nine 50-minute training sessions were held with OR staff as part of a broader perioperative EM implementation. Participants primarily included OR nurses and surgical technologists. The simulation-based in situ trainings included why and how to use EMs, familiarization with format, simulated scenarios of critical events, and debriefings. A retrospective pre-post survey was conducted to determine participants' levels of EM familiarity and intentions to use EMs clinically. RESULTS: The 126 trained OR staff self-reported increases in awareness of the EM (p < .01), familiarity with EM (p < .01), willingness to use for educational review (p < .01), and intention to use during critical events (p < .01). Participants rated the sessions highly and expressed interest in more opportunities to practice using EMs. CONCLUSIONS: Implementing institutions should not only provide EMs in accessible places in ORs but also incorporate training mechanisms to increase clinicians' familiarity, cultural acceptance, and planned clinical use.

Estimating population size, HIV prevalence and HIV incidence among men who have sex with men: a case example of synthesising multiple empirical data sources and methods in San Francisco.

OBJECTIVE: The number of persons living with HIV/AIDS, the number of new infections and the number of persons at risk for HIV infection are the foundations of evidence-based prevention, treatment and care planning. However, few jurisdictions have complete and accurate estimates of these indicators. HIV/AIDS case reporting, which includes only persons diagnosed with infection and reported to health departments, does not reflect all HIV/AIDS cases, thus underestimating the true size of the epidemic. Obtaining direct measures of HIV incidence is methodologically challenging. Moreover, no censuses exist for the number of persons at highest risk for infection, including men who have sex with men (MSM). METHOD: We present an approach of triangulation that draws upon multiple empirical and overlapping sources of information through different methods to synthesise data-based estimates of the prevalence, incidence and denominator of MSM at risk for infection in San Francisco. We further use existing data to establish plausible upper and lower bounds for each estimate. RESULT: We arrived at an overall population size of 66 487 of MSM in San Francisco as of 31 December 2010. The number of MSM living with HIV/AIDS was 15 873, corresponding to an HIV prevalence of 23.9%. We projected 806 new cases in 2010, translating to an incidence rate of 1.59% per year. CONCLUSIONS: While not without limitations, our estimates provide useful information for the purpose of HIV/AIDS prevention and care planning, drawing from diverse sources that may be available in local health jurisdictions. We believe that our approach enhances the credibility of such estimates by mitigating bias from only one source of data or one methodological approach.

Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research.

BACKGROUND: Cultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities. OBJECTIVE: The objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research. DESIGN: The authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included. MEASUREMENTS: Four authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted. RESULTS: Seven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect. CONCLUSION: There is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.

Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage.

INTRODUCTION: Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE. METHODS: We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed. RESULTS: Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval. CONCLUSION: The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention. LEVEL OF EVIDENCE: Economic, level IV.

Surmounting the unique challenges in health disparities education: a multi-institution qualitative study.

BACKGROUND: The National Consortium for Multicultural Education for Health Professionals (Consortium) comprises educators representing 18 US medical schools, funded by the National Institutes of Health. Collective lessons learned from curriculum implementation by principal investigators (PIs) have the potential to guide similar educational endeavors. OBJECTIVE: Describe Consortium PI's self-reported challenges with curricular development, solutions and their new curricular products. METHODS: Information was collected from PIs over 2 months using a 53-question structured three-part questionnaire. The questionnaire addressed PI demographics, curriculum implementation challenges and solutions, and newly created curricular products. Study participants were 18 Consortium PIs. Descriptive analysis was used for quantitative data. Narrative responses were analyzed and interpreted using qualitative thematic coding. RESULTS: Response rate was 100%. Common barriers and challenges identified by PIs were: finding administrative and leadership support, sustaining the momentum, continued funding, finding curricular space, accessing and engaging communities, and lack of education research methodology skills. Solutions identified included engaging stakeholders, project-sharing across schools, advocacy and active participation in committees and community, and seeking sustainable funding. All Consortium PIs reported new curricular products and extensive dissemination efforts outside their own institutions. CONCLUSION: The Consortium model has added benefits for curricular innovation and dissemination for cultural competence education to address health disparities. Lessons learned may be applicable to other educational innovation efforts.

Beyond knowledge, toward linguistic competency: an experiential curriculum.

INTRODUCTION/AIMS: Training is essential for future health care providers to effectively communicate with limited English proficient (LEP) patients during interpreted encounters. Our aim is to describe an innovative skill-based medical school linguistic competency curriculum and its impact on knowledge and skills. SETTING: At Stanford University School of Medicine, we incorporated a linguistic competency curriculum into a 2-year Practice of Medicine preclinical doctoring course and pediatrics clerkship over three cohorts. PROGRAM DESCRIPTION: First year students participated in extensive interpreter-related training including: a knowledge-based online module, interactive role-play exercises, and didactic skill-building sessions. Students in the pediatrics clerkship participated in interpreted training exercises with facilitated feedback. PROGRAM EVALUATION: Knowledge and skills were evaluated in the first and fourth years. First year students' knowledge scores increased (pre-test = 0.62, post-test = 0.89, P < 0.001), and they demonstrated good skill attainment during an end-year performance assessment. One cohort of students participated in the entire curriculum and maintained performance into the fourth year. DISCUSSION: Our curriculum increased knowledge and led to skill attainment, each of which showed good durability for a cohort of students evaluated 3 years later. With a growing LEP population, these skills are essential to foster in future health care providers to effectively communicate with LEP patients and reduce health disparities.

Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke?

BACKGROUND: Stroke is a leading cause of disability and the fifth leading cause of death in the USA. Intravenous alteplase is a highly effective clot-dissolving stroke treatment that must be given in a hospital setting within a time-sensitive window. To increase the use of intravenous alteplase in stroke patients, many US counties enacted policies mandating emergency medical service (EMS) paramedics to bypass local emergency departments and instead directly transport patients to specially equipped stroke centers. The objective of this mixed-methods study is to evaluate the effectiveness of policy enactment as an implementation strategy, how differences in policy structures and processes impact effectiveness, and to explore how the county, hospital, and policy factors explain variation in implementation and clinical outcomes. This paper provides a detailed description of an Agency for Healthcare Quality and Research (AHRQ)-funded protocol, including the use of the Consolidated Framework for Implementation Research (CFIR) in the qualitative design. METHODS/DESIGN: We will construct the largest-ever national stroke database of Medicare enrollees (~ 1.5 million stroke patients) representing 896 policy counties paired with 1792 non-policy counties, then integrate patient-, hospital-, county-, and state-level covariates from eight different data sources. We will use a difference-in-differences analysis to estimate the overall effect of the policy enactment on intravenous alteplase use (implementation outcome) as well as key patient outcomes. We will also quantitatively examine if variation in the context (urban/rural status) and variation in policy features affect outcomes. Finally, a CFIR-informed multiple case study design will be used to interview informants in 72 stakeholders in 24 counties to identify and validate factors that enable policy effects. DISCUSSION: Policies can be potent implementation strategies. However, the effects of EMS bypass policies to increase intravenous alteplase use have not been rigorously evaluated. By learning how context and policy structures impact alteplase implementation, as well as the barriers and facilitators experienced by stakeholders responsible for policy enactment, the results of this study will inform decisions regarding if and how EMS bypass policies should spread to non-policy counties, and if indicated, creation of a "best practices" toolkit.

Informed decision-making and colorectal cancer screening: is it occurring in primary care?

BACKGROUND: Current recommendations advise patients to participate in the decision-making for selecting a colorectal cancer (CRC) screening option. The degree to which providers communicate the information necessary to prepare patients for participation in this process is not known. OBJECTIVE: To assess the level of informed decision-making occurring during actual patient-provider communications on CRC screening and test for the association between informed decision-making and screening behavior. RESEARCH DESIGN: Observational study of audiotaped clinic visits between patients and their providers in the primary care clinic at a Veterans Administration Medical Center. SUBJECTS: Male patients, age 50-74 years, presenting to a primary care visit at the study site. MEASURES: The Informed Decision-Making (IDM) Model was used to code the audiotapes for 9 elements of communication that should occur to prepare patients for participation in decision-making. The primary outcome is completion of CRC screening during the study period. RESULTS: The analytic cohort consisted of 91 patients due for CRC screening who had a test ordered at the visit. Six of the 9 IDM elements occurred in < or =20% of the visits with none addressed in > or =50%. CRC screening occurred less frequently for those discussing "pros and cons" (12% vs. 46%, P = 0.01) and "patient preferences" (6% vs. 47%, P = 0.001) compared with those who did not. CONCLUSIONS: We found that a lack of informed decision-making occurred during CRC screening discussions and that particular elements of the process were negatively associated with screening. Further research is needed to better understand the effects of informed decision-making on screening behavior.

Toward shared decision making at the end of life in intensive care units: opportunities for improvement.

BACKGROUND: In North America, families generally wish to be involved in end-of-life decisions when the patient cannot participate, yet little is known about the extent to which shared decision making occurs in intensive care units. METHODS: We audiotaped 51 physician-family conferences about major end-of-life treatment decisions at 4 hospitals from August 1, 2000, to July 31, 2002. We measured shared decision making using a previously validated instrument to assess the following 10 elements: discussing the nature of the decision, describing treatment alternatives, discussing the pros and cons of the choices, discussing uncertainty, assessing family understanding, eliciting patient values and preferences, discussing the family's role in decision making, assessing the need for input from others, exploring the context of the decision, and eliciting the family's opinion about the treatment decision. We used a mixed-effects regression model to determine predictors of shared decision making and to evaluate whether higher levels of shared decision making were associated with greater family satisfaction. RESULTS: Only 2% (1/51) of decisions met all 10 criteria for shared decision making. The most frequently addressed elements were the nature of the decision (100%) and the context of the decision to be made (92%). The least frequently addressed elements were the family's role in decision making (31%) and an assessment of the family's understanding of the decision (25%). In multivariate analysis, lower family educational level was associated with less shared decision making (partial correlation coefficient, 0.34; standardized beta, .3; P = .02). Higher levels of shared decision making were associated with greater family satisfaction with communication (partial correlation coefficient, 0.15; standardized beta, .09; P = .03). CONCLUSIONS: Shared decision making about end-of-life treatment choices was often incomplete, especially among less educated families. Higher levels of shared decision making were associated with greater family satisfaction. Shared decision making may be an important area for quality improvement in intensive care units.

Validating measures of third year medical students' use of interpreters by standardized patients and faculty observers.

BACKGROUND: Increasing prevalence of limited English proficiency patient encounters demands effective use of interpreters. Validated measures for this skill are needed. OBJECTIVE: We describe the process of creating and validating two new measures for rating student skills for interpreter use. SETTING: Encounters using standardized patients (SPs) and interpreters within a clinical practice examination (CPX) at one medical school. MEASUREMENTS: Students were assessed by SPs using the interpreter impact rating scale (IIRS) and the physician patient interaction (PPI) scale. A subset of 23 encounters was assessed by 4 faculty raters using the faculty observer rating scale (FORS). Internal consistency reliability was assessed by Cronbach's coefficient alpha (alpha). Interrater reliability of the FORS was examined by the intraclass correlation coefficient (ICC). The FORS and IIRS were compared and each was correlated with the PPI. RESULTS: Cronbach's alpha was 0.90 for the 7-item IIRS and 0.88 for the 11-item FORS. ICC among 4 faculty observers had a mean of 0.61 and median of 0.65 (0.20, 0.86). Skill measured by the IIRS did not significantly correlate with FORS but correlated with the PPI. CONCLUSIONS: We developed two measures with good internal reliability for use by SPs and faculty observers. More research is needed to clarify the reasons for the lack of concordance between these measures and which may be more valid for use as a summative assessment measure.

Effectiveness of the Surgery Core Clerkship Flipped Classroom: a prospective cohort trial.

BACKGROUND: The flipped classroom has been proposed as an alternative curricular approach to traditional didactic lectures but has not been previously applied to a surgery clerkship. METHODS: A 1-year prospective cohort of students (n = 89) enrolled in the surgery clerkship was taught using a flipped classroom approach. A historical cohort of students (n = 92) taught with a traditional lecture curriculum was used for comparison. Pretest and post-test performance, end-of-clerkship surveys, and National Board of Medical Examiners (NBME) scores were analyzed to assess effectiveness. RESULTS: Mean pretest and post-test scores increased across all modules (P < .001). There was no difference between mean NBME examination score in the prospective and historical cohorts (74.75 vs 75.74, P = .28). Mean ratings of career interest in surgery increased after curriculum completion (4.75 to 6.50, P < .001), with 90% reporting that the flipped classroom contributed to this increase. CONCLUSIONS: Implementation of a flipped classroom in the surgery clerkship is feasible and results in high learner satisfaction, effective knowledge acquisition, and increased career interest in surgery with noninferior NBME performance.

Training health care professionals for 21st-century practice: a systematic review of educational interventions on chronic care.

PURPOSE: To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care. METHOD: A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention. RESULTS: A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives. CONCLUSIONS: The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.

The impact of a faculty development program in health literacy and ethnogeriatrics.

PROBLEM: A faculty development curriculum aimed at increasing health literacy and awareness of patient care issues in ethnogeriatrics is essential to address serious deficiencies in faculty and health professionals' training and to prepare future health care professionals to care for older adults. APPROACH: Authors from the Stanford Geriatric Education Center developed and implemented a faculty development program in Health Literacy and Ethnogeriatrics (HLE). The goal was to enhance faculty and health professionals' knowledge, skills, and attitudes in HLE-related areas (e.g., health disparities, low health literacy, quality of care for ethnically diverse elders, patient/provider communication). The curriculum was implemented during an intensive weeklong program over a three-year period (2008-2010). The eight-module core curriculum was presented in a train-the-trainer format, supplemented by daily resource sessions. OUTCOMES: Thirty-four faculty participants from 11 disciplines, including medicine, came from 19 institutions in 12 states. The curriculum positively affected participants' knowledge, skills, and attitudes related to topics in HLE. Participants rated the curriculum's usefulness highly, and they reported that over 57% of the content was new. The HLE curriculum provided a mechanism to increase the self-assessed knowledge, skills, and attitudes of participants. It also fostered local curricular change: Over 91% of the participants have either disseminated the HLE curriculum through seminars conducted at their home sites or implemented HLE-related projects in their local communities, reaching diverse patient populations. NEXT STEPS: Next steps include measuring the impact on the participants' teaching skills and at their home sites through their trainees and patients.

The prevalence of social and behavioral topics and related educational opportunities during attending rounds.

PURPOSE: To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced. METHOD: This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes-prevalence of SBS topic discussions and rate of positive responses to discussions-were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors. RESULTS: Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams' responses were positive. Services varied with respect to learner- and patient-centeredness, with most services above average for learner-centered, and below average for patient-centered behaviors. CONCLUSIONS: Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patient-centered behaviors.

New elements for informed decision making: a qualitative study of older adults' views.

OBJECTIVE: To explore older adults' views of existing informed decision making (IDM) elements and investigate the need for additional elements. METHODS: We recruited persons 65 and older to participate in six focus groups. Participants completed questionnaires about IDM preferences, and discussed videotapes of idealized patient-physician interactions in light of seven IDM elements: (1) discussion of the patient's role in decision making; (2) discussion of the clinical issue; (3) discussion of alternatives; (4) discussion of benefits/risks; (5) discussion of uncertainties; (6) assessment of patient understanding; and (7) exploration of patient preference. We used a modified grounded theory approach to assess agreement with existing IDM elements and identify new elements. RESULTS: In questionnaires, 97-100% of 59 participants rated each IDM element as "somewhat" or "very" important. Qualitative analysis supported existing elements and suggested two more: opportunity for input from trusted others, and discussion of decisions' impacts on patients' daily lives. Elements overlapped with global communication themes. CONCLUSION: Focus groups affirmed existing IDM elements and suggested two more with particular relevance for older patients. PRACTICE IMPLICATIONS: Incorporation of additional IDM elements into clinical practice can enhance informed participation of older adults in decision making.

Measuring informed decision making about prostate cancer screening in primary care.

PURPOSE: To measure the extent of informed decision making (IDM) about prostate cancer screening in physician-patient encounters, describe the coding process, and assess the reliability of the IDM measure. METHODS: Audiorecoded encounters of 146 older adult men and their primary care physicians were obtained in a randomized controlled trial of mediated decision support related to prostate cancer screening. Each encounter was dual coded for the presence or absence of 9 elements that reflect several important dimensions of IDM, such as information sharing, patient empowerment, and engaging patients in preference clarification. An IDM-9 score (range = 0-9) was determined for each encounter by summing the number of elements that were coded as present. Estimates of coding reliability and internal consistency were calculated. RESULTS: Male patients tended to be white (59%), married (70%), and between the ages of 50 and 59 (70%). Physicians tended to be white (90%), male (74%), and have more than 10 years of practice experience (74%). IDM-9 scores ranged from 0 to 7.5 (mean [SD], 2.7 [2.1]). Reliability (0.90) and internal consistency (0.81) of the IDM-9 were both high. The IDM dimension observed most frequently was information sharing (74%), whereas the dimension least frequently observed was engagement in preference clarification (3.4%). CONCLUSIONS: In physician-patient encounters, the level of IDM concerning prostate cancer screening was low. The use of a dual-coding approach with audiorecorded encounters produced a measure of IDM that was reliable and internally consistent.

Relationships of the location and content of rounds to specialty, institution, patient-census, and team size.

OBJECTIVE: Existing observational data describing rounds in teaching hospitals are 15 years old, predate duty-hour regulations, are limited to one institution, and do not include pediatrics. We sought to evaluate the effect of medical specialty, institution, patient-census, and team participants upon time at the bedside and education occurring on rounds. METHODS AND PARTICIPANTS: Between December of 2007 and October of 2008 we performed 51 observations at Lucile Packard Children's Hospital, Seattle Children's Hospital, Stanford University Hospital, and the University of Washington Medical Center of 35 attending physicians. We recorded minutes spent on rounds in three location and seven activity categories, members of the care team, and patient-census. RESULTS: Results presented are means. Pediatric rounds had more participants (8.2 vs. 4.1 physicians, p<.001; 11.9 vs. 2.4 non-physicians, p<.001) who spent more minutes in hallways (96.9 min vs. 35.2 min, p<.001), fewer minutes at the bedside (14.6 vs. 38.2 min, p = .01) than internal medicine rounds. Multivariate regression modeling revealed that minutes at the bedside per patient was negatively associated with pediatrics (-2.77 adjusted bedside minutes; 95% CI -4.61 to -0.93; p<.001) but positively associated with the number of non-physician participants (0.12 adjusted bedside minutes per non physician participant; 95% CI 0.07 to 0.17; p = <.001). Education minutes on rounds was positively associated with the presence of an attending physician (2.70 adjusted education minutes; 95% CI 1.27 to 4.12; p<.001) and with one institution (1.39 adjusted education minutes; 95% CI 0.26 to 2.53; p = .02). CONCLUSIONS: Pediatricians spent less time at the bedside on rounds than internal medicine physicians due to reasons other than patient-census or the number of participants in rounds. Compared to historical data, internal medicine rounds were spent more at the bedside engaged in patient care and communication, and less upon educational activities.