The "Difficult" Inpatient, a Qualitative Study of Physician Perspectives.

BACKGROUND: Previous studies exploring difficult inpatients have mostly focused on psychiatric inpatients. OBJECTIVE: To explore the characteristics of difficult medicine inpatients. DESIGN: Qualitative study using focus groups and semi-structured interviews. Transcripts were recorded, transcribed, and coded (MAXQDA) using thematic content analysis. PARTICIPANTS: Medicine inpatient providers at a tertiary care facility. KEY RESULTS: Our sample consisted of 28 providers (6 hospitalists, 10 medicine attendings, 6 medicine residents, and 6 interns). Theme 1: Provider experience: Difficult inpatients were time-consuming and evoked emotional responses including frustration and dysphoria. Theme 2: Patient characteristics: Included having personality disorders or mental health issues, being uncooperative, manipulative, angry, demanding, threatening, or distrustful. Difficult patients also had challenging social situations and inadequate support, unrealistic care expectations, were self-destructive, tended to split care-team messages, and had unclear diagnoses. Theme 3: Difficult families: Shared many characteristics of difficult patients including being distrustful, demanding, manipulative, threatening, or angry. Difficult families were barriers to care, disagreed with the treatment plan and each other, did not act in the patient's best interest, suggested inappropriate treatment, or had unrealistic expectations. STRATEGIES: Approaches to dealing with difficult patients or families included building trust, being calm, and having a consistent message. Communication approaches included naming the emotion, empathetic listening, identifying patient priorities and barriers, and partnering. CONCLUSIONS: Difficult patients induced emotional responses, dysphoria, and self-doubt among providers. Underlying personality disorders were often mentioned. Difficult patients and families shared many characteristics. Communication and training were highlighted as key strategies.

A Comparative Study of Scripted versus Unscripted Morning Reports: Results from a Prospective Multicenter Study.

OBJECTIVES: Morning report is one of the central activities of internal medicine residency education. The two most common morning report formats are scripted reports, which use preselected cases with prepared didactics, and unscripted reports in which a case is discussed without preparation. No previous study has compared these two formats. METHODS: We conducted a prospective observational study of morning report conducted at 10 academic medical centers across the United States. RESULTS: A total of 198 case-based morning reports were observed. Of these, 169 (85%) were scripted and 29 (15%) were unscripted. Scripted reports were more likely to present a case with a known final diagnosis (89% vs 76%, P = 0.04), use electronic slides (76% vs 52%, P = 0.01), involve more than 15 slides (55% vs 3%, P < 0.001), and reference the medical literature (61% vs 34%, P = 0.02), including professional guidelines (32% vs 10%, P = 0.02) and original research (25% vs 0%, P = 0.001). Scripted reports also consumed more time in prepared didactics (8.0 vs 0 minutes, P < 0.001). Unscripted reports consumed more time in case history (10.0 vs 7.0 minutes, P < 0.001), physical examination (3.0 vs 2.0 minutes, P = 0.06), and differential diagnosis (10.0 vs 7.0 minutes, P = 0.01). CONCLUSIONS: Most contemporary morning reports are scripted. Compared with traditional unscripted reports, scripted reports are more likely to involve a case with a known diagnosis, use extensive electronic presentation slides, and consume more time in didactics, while unscripted reports consume more time in the early diagnostic process, including history, physical examination, and differential diagnosis. Residency programs interested in emphasizing these aspects of medical education should encourage unscripted morning reports.

Patient-Physician Concordance for Quantitative Formats and Treatment Options and the Relationship with State Anxiety.

Patient-physician concordance about topics discussed in a clinic visit is essential for effective communication but may be difficult to achieve in cancer care. We conducted a multicenter, observational study at two Midwestern oncology clinics. A sample of 48 English-speaking or Spanish-speaking women with newly diagnosed stage 0-3 breast cancer completed surveys before and after a visit with an oncologist. Patient-physician dyads were coded as concordant if both patient and physician follow-up self-reports agreed whether (or not) specific treatments were discussed (i.e., treatment option concordance; mastectomy, lumpectomy, hormone therapy, neoadjuvant, and adjuvant chemotherapy) and whether risk was described using certain quantitative formats (i.e., quantitative format concordance; percentages, proportions out of 100 and 1000, graphs, pictures, evidence from clinical studies, cancer stage). Agreement was determined using percent agreement and prevalence-adjusted bias-adjusted kappa (PABAK). Pearson's correlations were used to determine relationships between anxiety and each measure concordance. Percent concordance was higher for treatment concordance (73.3%) compared to quantitative format concordance (64.5%), and PABAK scores tended to be higher for treatment options (PABAK = .21-.78). Both treatment and quantitative format concordance were negatively associated with pre-visit state anxiety, but only treatment concordance was statistically significant (treatment: r = - .504, p = .001; quantitative format: r = - .096, p = .523). Our study indicates moderate patient-physician concordance in early breast cancer care communication and that patient anxiety may impact the ability for patients and physicians to agree on the content communicated in a clinic visit.

Barriers to Accessing Nighttime Supervisors: a National Survey of Internal Medicine Residents.

BACKGROUND: Single-center studies have reported residents experience barriers to accessing supervising physicians overnight, but no national dataset has described barriers perceived by residents or the association between supervision models and perceived barriers. OBJECTIVE: To explore residents' perception of barriers to accessing overnight supervision. DESIGN: Questions about overnight supervision and barriers to accessing it were included on the American College of Physicians Internal Medicine In-Training Examination® (IM-ITE®) Resident Survey in Fall 2017. PARTICIPANTS: All US-based internal medicine residents who completed the 2017 IM-ITE®. Responses from 20,744 residents (84%) were analyzed. MAIN MEASURES: For our main outcome, we calculated percentages of responses for eight barriers and tested for association with the presence or absence of nocturnists. For our secondary outcome, we categorized free-text responses enumerating barriers from all residents into the five Systems Engineering Initiative for Patient Safety (SEIPS) categories to elucidate future areas for study or intervention. KEY RESULTS: Internal medicine residents working in hospitals without nocturnists more commonly reported having at least one barrier to accessing a supervising physician "always" or "most of the time" (5075/9842, 51.6%) compared to residents in hospitals with nocturnists (3074/10,902, 28.2%, p < 0.001). Among residents in hospitals without nocturnists, the most frequently reported barrier to accessing attending supervision was attendings not being present in the hospital (30.4% "always" or "most of the time"); residents in hospitals with nocturnists most frequently reported desire to make their own decisions as a barrier to contacting attendings (15.7% "always" or "most of the time"). Free-text responses from residents with and without nocturnists most commonly revealed organization (47%) barriers to accessing supervision; 28% cited person barriers, and 23% cited tools/technology barriers. CONCLUSIONS: Presence of nocturnists is associated with fewer reported barriers to contacting supervising physicians overnight. Organizational culture, work schedules, desire for independence, interpersonal interactions, and technology may present important barriers.

The Challenges, Joys, and Career Satisfaction of Women Graduates of the Robert Wood Johnson Clinical Scholars Program 1973-2011.

BACKGROUND: To ensure a next generation of female leaders in academia, we need to understand challenges they face and factors that enable fellowship-prepared women to thrive. We surveyed woman graduates of the Robert Wood Johnson Clinical Scholars Program (CSP) from 1976 to 2011 regarding their experiences, insights, and advice to women entering the field. METHODS: We surveyed every CSP woman graduate through 2012 (n = 360) by email and post. The survey, 12 prompts requiring open text responses, explored current work situation, personal definitions of success, job negotiations, career regrets, feelings about work, and advice for others. Four independent reviewers read overlapping subsets of the de-identified data, iteratively created coding categories, and defined and refined emergent themes. RESULTS: Of the 360 cohort, 108 (30%) responded. The mean age of respondents was 45 (range 32 to 65), 85% are partnered, and 87% have children (average number of children 2.15, range 1 to 5). We identified 11 major code categories and conducted a thematic analysis. Factors common to very satisfied respondents include personally meaningful work, schedule flexibility, spousal support, and collaborative team research. Managing professional-personal balance depended on career stage, clinical specialty, and children's age. Unique to women who completed the CSP prior to 1995 were descriptions of "atypical" paths with career transitions motivated by discord between work and personal ambitions and the emphasis on the importance of maintaining relevance and remaining open to opportunities in later life. CONCLUSIONS: Women CSP graduates who stayed in academic medicine are proud to have pursued meaningful work despite challenges and uncertain futures. They thrived by remaining flexible and managing change while remaining true to their values. We likely captured the voices of long-term survivors in academic medicine. Although transferability of these findings is uncertain, these voices add to the national discussion about retaining clinical researchers and keeping women academics productive and engaged.

Sexual Harassment of Female Providers by Patients: a Qualitative Study.

BACKGROUND: Sexual harassment of women is a pervasive problem. Prior studies found that sexual harassment of female providers by patients is common, but guidance on addressing this problem is limited. OBJECTIVE: To understand the experiences of female providers with sexual harassment by patients with a focus on how practicing providers address these events. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Twenty female, internal medicine providers, including resident physicians, staff physicians, and nurse practitioners at a large, urban, academic hospital in the USA. APPROACH: Interviews were analyzed for themes. KEY RESULTS: Two themes were explored: first, the experiences with sexual harassment and, second, the strategies to address sexual harassment. We coded four sub-themes regarding participant experiences: (1) their descriptions of the types of harassment, (2) the context of the event, (3) the impact of the harassment, and (4) their preparation to address the harassment. We coded seven sub-themes on strategies used by participants: (1) indirect strategies, (2) confrontation, (3) modifying the clinical encounter, (4) modifying self, (5) alerting others, (6) debrief, and (7) report. CONCLUSION: Our qualitative study found that sexual harassment of female providers by patients is an ongoing problem, disruptive to the patient-provider relationship, and a possible threat to the well-being of both provider and patient. Formal training on how to address this problem was lacking, but all providers had developed or adapted strategies based on personal experiences or role modeling. Educating providers on strategies is an important next step to addressing this problem.

The Experience of Male Physicians with Sexual and Gender-Based Harassment: a Qualitative Study.

BACKGROUND: Sexual harassment and gender-based harassment are common in medicine; however, there is little in the literature regarding men's experience with gender-based and sexual harassment. OBJECTIVE: The objective of this study was to better understand the experience men have with sexual and gender-based harassment in medicine. DESIGN: We developed and piloted an interview guide based on a review of the literature and conducted semi-structured interviews of male physicians, from trainees to attendings, at a tertiary care facility. Participants were recruited via email between April and August of 2019. These interviews were transcribed verbatim and, using an iterative coding approach based in grounded theory, were coded and analyzed for themes. MAIN RESULTS: We conducted a total of 16 interviews. Five major themes were identified: (1) personal experiences of harassment, (2) witnessed harassment, (3) characterization of harassment, (4) impact of harassment, and (5) strategies for responding to harassment. The men reported experiences with sexual and gender-based harassment but were hesitant to define these encounters as such. They had minimal emotional distress from these encounters but worried about their professional reputation and lacked training for how to respond to these encounters. Many had also witnessed their female colleagues being harassed by both male patients and colleagues but did not respond to or stop the harassment when it originated from a colleague. CONCLUSION: We found that men experience sexual harassment differently from women. Most notably, men report less emotional distress from these encounters and often do not define these events as harassment. However, similar to women, men feel unprepared to respond to episodes of harassment against themselves or others. Whether to deter sexual harassment against themselves, or, more commonly, against a female colleague, men can gain the tools to speak up and be part of the solution to sexual harassment in medicine.

A Multicenter VA Study of the Format and Content of Internal Medicine Morning Report.

BACKGROUND: There are more than five hundred internal medicine residency programs in the USA, involving 27,000 residents. Morning report is a central educational activity in resident education, but no recent studies describe its format or content. OBJECTIVE: To describe the format and content of internal medicine morning reports. DESIGN AND PARTICIPANTS: Prospective observational study of morning reports occurring between September 1, 2018, and April 30, 2019, in ten different VA academic medical centers in the USA. MAIN MEASURES: Report format, number and type of learner, number and background of attending, frequency of learner participation, and the type of media used. Content areas including quality and safety, high-value care, social determinants of health, evidence-based medicine, ethics, and bedside teaching. For case-based reports, the duration of different aspects of the case was recorded, the ultimate diagnosis when known, and if the case was scripted or unscripted. RESULTS: A total of 225 morning reports were observed. Reports were predominantly case-based, moderated by a chief resident, utilized digital presentation slides, and involved a range of learners including medicine residents, medical students, and non-physician learners. The most common attending physician present was a hospitalist. Reports typically involved a single case, which the chief resident reviewed prior to report and prepared a teaching presentation using digital presentation slides. One-half of cases were categorized as either rare or life-threatening. The most common category of diagnosis was medication side effects. Quality and safety, high-value care, social determinants of health, and evidence-based medicine were commonly discussed. Medical ethics was rarely addressed. CONCLUSIONS: Although a wide range of formats and content were described, internal medicine morning report most commonly involves a single case that is prepared ahead of time by the chief resident, uses digital presentation slides, and emphasizes history, differential diagnosis, didactics, and rare or life-threatening diseases.

Emotional Content of Comics Drawn by Medical Students and Residents.

OBJECTIVE: Medical students and residents face high rates of burnout. Drawing comics may help trainees process their experiences and feel both valued and connected to those who read their work. In this study, the authors sought to elucidate the predominant emotions and themes conveyed in medical students' and residents' comics about stressful situations. METHODS: In 10 different sessions, medical trainees drew "something stressful in medicine". Collected comics were analyzed by three coders, who applied emotional adjectives. Differences were resolved through discussion, with one to two final codes per comic. Codes coded based on items objectively seen in the comic and were encouraged not to project what they would feel in that situation. RESULTS: Two hundred ninety comics were analyzed by our research group. "Overwhelmed" was the most common final code (101 comics, 34.8%). Other common adjectives used by our coders to describe the comics were "inadequate" (24, 8.2%), "frustrated" (21, 7.2%), and "helpless" (16, 5.5%). Twelve of the comics (4%) were considered non-codable because of difficulty deciphering the theme or print. CONCLUSIONS: Brief comic exercises allowed medical trainees to convey what it is like to be "stressed out" in medical training-with trainees most often showing that they are/feel "overwhelmed," "inadequate," "frustrated," and "helpless." This demonstrates that medical students and residents convey these same emotions when reflecting on individual stressful experiences throughout their training. More research on whether graphic medicine for emotional and cognitive processing of stress makes an impact on burnout and satisfaction is warranted.

Development and Validation of the Spanish Numeracy Understanding in Medicine Instrument.

BACKGROUND: The Spanish-speaking population in the U.S. is large and growing and is known to have lower health literacy than the English-speaking population. Less is known about the health numeracy of this population due to a lack of health numeracy measures in Spanish. OBJECTIVE: we aimed to develop and validate a short and easy to use measure of health numeracy for Spanish-speaking adults: the Spanish Numeracy Understanding in Medicine Instrument (Spanish-NUMi). DESIGN: Items were generated based on qualitative studies in English- and Spanish-speaking adults and translated into Spanish using a group translation and consensus process. Candidate items for the Spanish NUMi were selected from an eight-item validated English Short NUMi. Differential Item Functioning (DIF) was conducted to evaluate equivalence between English and Spanish items. Cronbach's alpha was computed as a measure of reliability and a Pearson's correlation was used to evaluate the association between test scores and the Spanish Test of Functional Health Literacy (S-TOFHLA) and education level. PARTICIPANTS: Two-hundred and thirty-two Spanish-speaking Chicago residents were included in the study. KEY RESULTS: The study population was diverse in age, gender, and level of education and 70 % reported Mexico as their country of origin. Two items of the English eight-item Short NUMi demonstrated DIF and were dropped. The resulting six-item test had a Cronbach's alpha of 0.72, a range of difficulty using classical test statistics (percent correct: 0.48 to 0.86), and adequate discrimination (item-total score correlation: 0.34-0.49). Scores were positively correlated with print literacy as measured by the S- TOFHLA (r = 0.67; p < 0.001) and varied as predicted across grade level; mean scores for up to eighth grade, ninth through twelfth grade, and some college experience or more, respectively, were 2.48 (SD ± 1.64), 4.15 (SD ± 1.45), and 4.82 (SD ± 0.37). CONCLUSIONS: The Spanish NUMi is a reliable and valid measure of important numerical concepts used in communicating health information.

Discharge Education for Residents: A Study of Trainee Preparedness for Hospital Discharge.

BACKGROUND: Safe hospital discharges have become a major focus in the national discussion on transitions of care and care coordination. Education on the hospital discharge process is evolving as the needs of trainees are better understood. PURPOSE: This study is a cross-sectional survey of residents in a Midwestern residency program about their confidence in safely discharging patients from the hospital, including how they have or have not learned to do so. METHODS: An anonymous paper questionnaire was distributed to a convenience sample of interns and residents at a weekly meeting of the residency program. RESULTS: Most residents reported a general confidence in their abilities to safely discharge patients from the hospital; however, further probing revealed that their confidence breaks down when required to competently perform specific tasks of the discharge process such as activity restrictions or facilitation of home care. More than 50% of house staff surveyed responded that their education in many specific aspects of the discharge process are lacking. CONCLUSION: Interdisciplinary care education, and the discharge summary in particular, warrant further scrutiny as a care transition tool and means of teaching safe hospital discharge to trainees. We present a questionnaire that may serve useful as an anonymous tool to gauge residents' educational needs.

A qualitative evaluation of geographical localization of hospitalists: how unintended consequences may impact quality.

BACKGROUND: Geographical localization of hospitalist teams to nursing units may have an impact on the quality of inpatient care. The perceptions of individuals who provide patient care in a localized model of care have not been adequately studied. OBJECTIVE: To determine the impact of geographic localization of hospitalist teams by evaluating the perceptions of hospitalists (faculty and physician assistants) localized to a single nursing unit and the nurses who staffed that unit. DESIGN: Focus group study. SUBJECTS: Six hospitalist faculty and three hospitalist physician assistants who provided patient care while localized to a single nursing unit, as well as 29 nurses who staffed the nursing unit where localization occurred. MAIN MEASURES: Themes that emerged from grounded theory analysis of focus group transcripts. KEY RESULTS: Participants perceived an overall positive impact of localization on the quality of patient care they provide and their workflow. The positive impact was mediated through proximity to patients and between members of the healthcare team, as well as through increased communication, decreased wasted time and increased teamwork. The participants also identified increased interruptions, variability in patient flow, mismatches in specialization and perverse incentives as mediating factors leading to unintended consequences. A model emerged that can inform future deployment and evaluation of localization interventions. CONCLUSIONS: Geographical localization of hospitalist teams is perceived to be desirable by both hospitalists and nurses. Others who attempt localization could use our conceptual model as a guide to maximize the benefit and minimize the unintended consequences of this intervention.

Development and validation of the numeracy understanding in Medicine Instrument short form.

Health numeracy can be defined as the ability to understand and use numeric information and quantitative concepts in the context of health. The authors previously reported the development of the Numeracy Understanding in Medicine Instrument (NUMi), a 20-item test developed using item response theory. The authors now report the development and validation of a short form of the NUMi. Item statistics were used to identify a subset of 8 items representing a range of difficulty and content areas. Internal reliability was evaluated with Cronbach's alpha. Divergent and convergent validity was assessed by comparing scores of the S-NUMI with existing measures of education, print and numeric health literacy, mathematic achievement, cognitive reasoning, and the original NUMi. The 8-item scale had adequate reliability (α=.72) and was strongly correlated to the 20-item NUMi (α=.92). S-NUMi scores were strongly correlated with the Lipkus Expanded Health Numeracy Scale (α=.62), the Wide Range of Achievement Test-Mathematics (α=.72), and the Wonderlic Cognitive Ability Test (α=.76). Moderate correlation was found with education level (α=.58) and print literacy as measured by the Test of Functional Health Literacy in Adults (α=.49). Results show that the short form of the NUMi is a reliable and valid measure of health numeracy feasible for use in clinical and research settings.

Building continuity in handovers with shorter residency duty hours.

As junior doctors work shorter hours in light of concerns about the harmful effects of fatigue on physician performance and health, it is imperative to consider how to ensure that patient safety is not compromised by breaks in the continuity of care. By reconceptualizing handover as a necessary bridge to continuity, and hence to safer patient care, the model of continuity-enhanced handovers has the potential to allay fears and improve patient care in an era of increasing fragmentation. "Continuity-enhanced handovers" differ from traditional handovers in several key aspects, including quality of information transferred, greater professional responsibility of senders and receivers, and a different philosophy of "coverage." Continuity during handovers is often achieved through scheduling and staffing to maximize the provision of care by members of the primary team who have first-hand knowledge of patients. In this way, senders and receivers often engage in intra-team handovers, which can result in the accumulation of greater common ground or shared understanding of the patients they collectively care for through a series of repeated interactions. However, because maximizing team continuity is not always possible, other strategies such as cultivating high-performance teams, making handovers active learning opportunities, and monitoring performance during handovers are also important. Medical educators and clinicians should work toward adopting and testing principles of continuity-enhanced handovers in their local practices and share successes so that innovation and learning may spread easily among institutions and practices.

Influence of the COVID-19 Pandemic on Health-Care Career Interests Among High School Students.

PURPOSE: This study investigates the influence of the COVID-19 pandemic on high school students' interest in health-care careers. METHODS: A voluntary web-based survey, approved by the Medical College of Wisconsin's Institutional Review Board, was administered across eight high schools in Milwaukee and its suburbs in Wisconsin. The survey collected students' demographic details, opinions on the health-care system's pandemic response, and their interest in health-care careers before and after the pandemic. RESULTS: Out of 2,949 respondents, 29.9% were already contemplating a health-care career before the pandemic, with 27.7% indicating increased interest thereafter. Students not previously interested in health-care careers registered an 11.5% increase in interest due to the pandemic. Notably, the pandemic significantly boosted health-care career interest among females and freshmen. DISCUSSION: The COVID-19 pandemic has distinctly influenced high school students' interest in health-care careers, notably among females and freshmen. This finding has implications for addressing projected health-care professional shortages.