In the Clinic. Deep venous thrombosis.

This issue provides a clinical overview of deep venous thrombosis, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

The Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC): development and multi-institution psychometric data.

This study was designed to develop a psychometrically sound instrument to measure attitudes toward interprofessional collaboration in health profession students and practitioners regardless of their professions and areas of practice. Based on a review of the literature a list of 27 items was generated, 12 faculty judged the face validity of the items, and 124 health profession faculty examined the content validity of the items. The preliminary version of the instrument was administered to 1976 health profession students in three universities (Thomas Jefferson University, n = 510; Midwestern University, n = 392; and Monash University, n = 1074). Twenty items that survived the psychometric scrutiny were included in the Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC). Two constructs of "working relationships" and "accountability" emerged from factor analysis of the JeffSATIC. Cronbach's α coefficients for the JeffSATIC ranged from 0.84 to 0.90 in the three samples. Women obtained significantly higher JeffSATIC mean scores than men. Medical students obtained lower mean score on the JeffSATIC than most other health profession students at the same university. Psychometric support from a relatively large sample size of students in a variety of health profession programs in this multi-institutional study is encouraging which adds to the credibility of the JeffSATIC.

Professionalism in radiology: ideals and challenges.

OBJECTIVE: The Physician Charter defines the obligations of professionalism as being based on three fundamental principles and 10 professional commitments. Choices faced in the daily clinical practice of radiology may present as challenges because of conflicts between the ideals of professionalism and the realities of practice and personal interests of the physician. CONCLUSION: The true medical professional strikes a mindful balance that realizes a stimulating and fulfilling practice of medicine without compromise of patient care.

Enhancing and sustaining empathy in medical students.

BACKGROUND: Empathy is an important component of physician competence that needs to be enhanced. AIM: To test the hypotheses that medical students' empathy can be enhanced and sustained by targeted activities. METHODS: This was a two-phase study in which 248 medical students participated. In Phase 1, students in the experimental group watched and discussed video clips of patient encounters meant to enhance empathic understanding; those in the control group watched a documentary film. Ten weeks later in Phase 2 of the study, students who were in the experimental group were divided into two groups. One group attended a lecture on empathy in patient care, and the other plus the control group watched a movie about racism. The Jefferson Scale of Empathy (JSE) was administered pre-post in Phase 1 and posttest in Phase 2. RESULTS: In Phase 1, the JSE mean score for the experimental group improved significantly (p < 0.01); no change in the JSE scores was observed in the control group. In Phase 2, the JSE mean score improvement was sustained in the group that attended the lecture, but not in the other group. No change in empathy was noticed in the control group. CONCLUSION: Research hypotheses were confirmed.

The implementation of a required book club for medical students and faculty.

More medical schools are incorporating wellness activities and the medical humanities into their curriculum. Finding implementable programming that is feasible and enjoyable is challenging. Both student participants and faculty who might facilitate programs are busy with clinical and educational responsibilities. Book club discussions in general are an activity that bring people together and expose groups to literature. In medical education, informal books clubs have been shown to increase camaraderie and expose participants to topics in medicine that they may not have encountered without the structure of the group assignment. At one large private urban medical school, all fourth year medical students were required to participate in a one-time hour-long book discussion with a faculty member one week before Match Day 2021. This paper describes the implementation of that program and discusses survey results from 179 students who broadly indicated that the books were enjoyable, the discussions were enriching, and that the program should continue for future classes of medical students.

Psychometrics of the scale of attitudes toward physician-pharmacist collaboration: a study with medical students.

BACKGROUND: Despite the emphasis placed on interdisciplinary education and interprofessional collaboration between physicians and pharmacologists, no psychometrically sound instrument is available to measure attitudes toward collaborative relationships. AIM: This study was designed to examine psychometrics of an instrument for measuring attitudes toward physician-pharmacist collaborative relationships for administration to students in medical and pharmacy schools and to physicians and pharmacists. METHODS: The Scale of Attitudes Toward Physician-Pharmacist Collaboration was completed by 210 students at Jefferson Medical College. Factor analysis and correlational methods were used to examine psychometrics of the instrument. RESULTS: Consistent with the conceptual framework of interprofessional collaboration, three underlying constructs, namely "responsibility and accountability;" "shared authority;" and "interdisciplinary education" emerged from the factor analysis of the instrument providing support for its construct validity. The reliability coefficient alpha for the instrument was 0.90. The instrument's criterion-related validity coefficient with scores of a validated instrument (Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration) was 0.70. CONCLUSIONS: Findings provide support for the validity and reliability of the instrument for medical students. The instrument has the potential to be used for the evaluation of interdisciplinary education in medical and pharmacy schools, and for the evaluation of patient outcomes resulting from collaborative physician-pharmacist relationships.

Association of Preoperative Disclosure of Resident Roles With Informed Consent for Cataract Surgery in a Teaching Program.

IMPORTANCE: Cataract surgery is the most commonly performed intraocular surgery. Academic centers have mandates to train the next surgeon generation, but resident roles are often hidden in the consent process. OBJECTIVE: To investigate associations of full preoperative disclosure of the resident role with patient consent rates and subjective experience of the consent process. DESIGN, SETTING, AND PARTICIPANTS: Full scripted disclosure of residents' roles in cataract surgery was delivered by the attending surgeon. Qualitative analysis was conducted from recorded interviews of patients postoperatively regarding consent process experience and choice of whether to allow resident participation. Associations were sought regarding demographic characteristics and consent rates. Patients were recruited though a private community office. Surgery was performed at a single hospital where resident training was routinely conducted. The study included systemically well patients older than 18 years with surgical cataract. They had no previous eye surgery, English fluency, and ability to engage in informed consent decision-making and postsurgery interview. Patients were ineligible if they had monocular cataracts, required additional simultaneous procedures, had history of ocular trauma, or had cataracts that were surgically technically challenging beyond the usual resident skill level. INTERVENTIONS: Eligible patients received an informed consent conversation by the attending physician in accordance with a script describing projected resident involvement in their cataract surgery. Postoperatively, patients were interviewed and responses were analyzed with a quantitative and thematic qualitative approach. MAIN OUTCOMES AND MEASURES: Consent rates to resident participation and qualitative experience of full disclosure process. RESULTS: Ninety-six patients participated. Participants were between ages 50 and 88 years, 53 were men (55.2%), and 75 were white (85.2%). A total of 54 of 96 participants (56.3%; 95% CI, 45.7%-66.4%) agreed to resident involvement. There were no associations between baseline characteristics and consent to resident involvement identified with any confidence, including race/ethnicity (60% [45 of 75] in white patients vs 30.8% [4 of 13] in nonwhite patients; difference, 29.2%; 95% CI, -0.7% to 57.3%; Fisher exact P = .07). Thematically, those who agreed to resident involvement listed trust in the attending surgeon, contributing to education, and supervision as contributing factors. Patients who declined stated fear and perceived risk as reasons. CONCLUSIONS AND RELEVANCE: Our results suggest 45.7% to 66.4% of community private practice patients would consent to resident surgery. Consent rates were not associated with demographic factors. Because residents are less often offered the opportunity to do surgery on private practice patients vs academic center patients, this may represent a resource for resident education.

Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelagatran or warfarin: assessment of incidence, case-fatality rate, time course and sites of bleeding, and risk factors for bleeding.

BACKGROUND: Ximelagatran is a novel direct thrombin inhibitor that can be administered as a fixed oral dose, without the need for anticoagulant monitoring. METHODS: We undertook a pooled analysis of 7329 patients with nonvalvular atrial fibrillation from the Stroke Prevention Using Oral Thrombin Inhibitor in Atrial Fibrillation III and V trials to compare bleeding outcomes in patients who received ximelagatran, 36 mg twice daily, or warfarin sodium (target international normalized ratio, 2.0-3.0). We determined annual risk of bleeding (any, major), case-fatality rate, time course and anatomic sites of major bleeding, and risk factors for major bleeding with ximelagatran and warfarin treatment. RESULTS: Annual incidence of any bleeding was 31.75% with ximelagatran and 38.82% with warfarin (relative risk reduction, 18.2%; 95% confidence interval [CI], 13.0-23.1; P<.001). Annual incidence of major bleeding was 2.01% with ximelagatran and 2.68% with warfarin (relative risk reduction, 25.1%; 95% CI, 3.2-42.1; P = .03). Case-fatality rate of bleeding was comparable in ximelagatran- and warfarin-treated patients (8.16% vs 8.09%; P = .98). Cumulative incidence of major bleeding was higher with warfarin than ximelagatran after 24 months of treatment (4.7% vs 3.7%; P = .04). Anatomic sites of bleeding were comparable with both treatments. Risk factors for bleeding with ximelagatran were as follows (hazard ratios and 95% CIs in parentheses): diabetes mellitus (1.81; 1.19-2.77; P = .006), previous stroke or transient ischemic attack (1.78; 1.16-2.73; P = .008), age 75 years or greater (1.70; 1.33-2.18; P<.001), and aspirin use (1.68; 1.08-2.59; P = .02). Risk factors for bleeding in warfarin-treated patients were previous liver disease (4.88; 1.55-15.39; P = .007); aspirin use (2.41; 1.69-3.43; P<.001); and age 75 years or greater (1.26; 1.03-1.52; P = .02). CONCLUSIONS: Treatment with ximelagatran, 36 mg twice daily, is associated with a lower risk of bleeding than warfarin in patients with nonvalvular atrial fibrillation. Aspirin use and increasing age were associated with an increased risk of bleeding in ximelagatran- and warfarin-treated patients.

HIPAA Compliance and Training: A Perfect Storm for Professionalism Education?

The HIPAA Rules continue to support and bolster the importance of protecting the privacy and security of patients' protected health information. The HIPAA training requirements are at the cornerstone of meaningful implementation and provide a ripe opportunity for critical education.

Underlying construct of empathy, optimism, and burnout in medical students.

OBJECTIVE: This study was designed to explore the underlying construct of measures of empathy, optimism, and burnout in medical students. METHODS: Three instruments for measuring empathy (Jefferson Scale of Empathy, JSE); Optimism (the Life Orientation Test-Revised, LOT-R); and burnout (the Maslach Burnout Inventory, MBI, which includes three scales of Emotional Exhaustion, Depersonalization, and Personal Accomplishment) were administered to 265 third-year students at Sidney Kimmel (formerly Jefferson) Medical College at Thomas Jefferson University. Data were subjected to factor analysis to examine relationships among measures of empathy, optimism, and burnout in a multivariate statistical model. RESULTS: Factor analysis (principal component with oblique rotation) resulted in two underlying constructs, each with an eigenvalue greater than one. The first factor involved "positive personality attributes" (factor coefficients greater than .58 for measures of empathy, optimism, and personal accomplishment). The second factor involved "negative personality attributes" (factor coefficients greater than .78 for measures of emotional exhaustion, and depersonalization). CONCLUSIONS: Results confirmed that an association exists between empathy in the context of patient care and personality characteristics that are conducive to relationship building, and considered to be "positive personality attributes," as opposed to personality characteristics that are considered as "negative personality attributes" that are detrimental to interpersonal relationships. Implications for the professional development of physicians-in-training and in-practice are discussed.

Benefits of more aggressive VTE prophylaxis in hospitalized medical patients.

Venous thromboembolism (VTE), which includes both deep vein thrombosis and pulmonary embolism, is a well-known risk in surgical patients, but it is also a significant and often unrecognized source of mortality and morbidity in hospitalized medical patients. The need for routine prophylaxis in the general medical population is increasingly supported.

Peer assessment among first year medical students in anatomy.

Peer assessment has been shown to be an effective tool to promote professionalism in medical students. Peer assessment may be particularly useful in anatomy dissection laboratory as the required close collaboration and long hours of anatomy laboratory provide students insights into their peers' work habits and interpersonal skills. The objective of this study was to quantitatively and qualitatively analyze the use of a validated peer assessment tool in Gross Anatomy. Students in a first year medical school class evaluated three members of their dissection group using an online survey tool. The mid-course and end-of-course evaluation included open-ended comments, as well as a five-point scale that measured three work habits, two interpersonal attributes and one overall score. All 267 students completed the assignment. The overall score and four of the five other assessed categories showed significant improvement from the mid- to end-of-course evaluations. Quantitative and qualitative data also revealed significant improvement among the students who received the lowest mid-course assessments. Seventy-six percent of the class agreed with the statement: "Based on the feedback I received, I made a change in how I worked with or taught my peers." The use of this peer assessment tool used by students in anatomy was associated with improvements in work habits and interpersonal attributes, particularly by the cohort of students who received the lowest mid-course feedback. Peer assessment offers students an opportunity to improve their interpersonal skills and work habits.

Empathic and sympathetic orientations toward patient care: conceptualization, measurement, and psychometrics.

PURPOSE: To develop instruments for measuring empathic and sympathetic orientations in patient care and to provide evidence in support of their psychometrics. METHOD: Third-year medical students at Jefferson Medical College responded to four clinical vignettes in 2010. For each vignette, students indicated the extent of their agreement with an empathic response (conveying their understanding of patients' concerns) and with a sympathetic response (sharing patients' feelings). The authors calculated, based on students' responses to the clinical vignettes, two measures of empathic and sympathetic orientation. Students also completed the Jefferson Scale of Empathy (JSE) and the Interpersonal Reactivity Index (IRI). RESULTS: Of the 258 students in the class, 201 (78%) responded to all four vignettes and completed the JSE and IRI. The authors confirmed construct validity of the measures of empathic and sympathetic orientation through factor analysis. The empathic orientation was significantly associated with the measure of empathy (as measured by the JSE) but not with measures of sympathy (as measured by specific scales of the IRI). Conversely, sympathetic orientation was significantly associated with measures of sympathy. Thus, these results support the validity of the empathic and sympathetic orientation measures as assessed by four clinical vignettes. Coefficient alphas for the two measures were, respectively, 0.79 and 0.84. CONCLUSIONS: The validated measures of empathic and sympathetic orientation provide research opportunities to enhance the understanding of the contributions of empathy and sympathy to physicians' competence and patient outcomes.