Writing Is Thinking: Implementation and Evaluation of an Internal Medicine Residency Clinical Reasoning and Documentation Curriculum.

With increasingly complicated patients and faster throughput, time for thorough critical thinking and thoughtful clinical documentation is limited, especially in the training environment. Advocating for the value of clinical documentation as a robust opportunity for critical thinking, we describe the implementation and evaluation of a clinical reasoning and documentation curriculum for internal medicine residents. Our curriculum employed facilitated discussion, practical application, and a resident-as-teacher model. Resident surveys showed improved perceptions of the clinical and educational value of clinical documentation. Residents reported increased feedback to interns about their documentation and more appreciation of documentation as a venue for critical thinking. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01570-5.

Integrating the Electronic Health Record Into Patient Encounters: An Introductory Standardized Patient Exercise for Preclinical Medical Students.

INTRODUCTION: Increasingly, use of the electronic health record (EHR) is interwoven into even the most basic patient care tasks. Accordingly, learning how to utilize the EHR during patient encounters is important for medical students as they develop their clinical skills. Existing EHR curricula have focused primarily on doctor-patient relationship skills. We developed a session for our preclinical students on EHR-related doctor-patient relationship skills as well as on using the EHR to verify data and focus one's history taking. METHODS: We developed student notes, three training videos, four standardized patient (SP) cases, and a simplified, simulated EHR based on these cases. Students reviewed the notes and videos prior to class. During class, students practiced EHR-related communication and data-collection strategies by interviewing an SP while interacting with the simulated EHR. Following each encounter, students received feedback from a small group of peers and faculty. RESULTS: Two-hundred eighty-nine second-year medical students participated this session in 2019 and 2020, and 27 (19%, 2019) and 40 (28%, 2020) students, respectively, completed the postsession evaluation. Most respondents rated the SP activity as extremely or quite effective for practicing doctor-patient relationship strategies while interacting with the EHR (89%, 2019; 83%, 2020) and for practicing verification of EHR data during a patient encounter (81%, 2019; 86%, 2020). DISCUSSION: This training session was effective for introducing preclinical medical students to fundamental concepts and skills related to incorporating the EHR into patient encounters and offers a low-cost approach to teaching early medical students these important skills.

Automated Frailty Screening At-Scale for Pre-Operative Risk Stratification Using the Electronic Frailty Index.

BACKGROUND: Frailty is associated with numerous post-operative adverse outcomes in older adults. Current pre-operative frailty screening tools require additional data collection or objective assessments, adding expense and limiting large-scale implementation. OBJECTIVE: To evaluate the association of an automated measure of frailty integrated within the Electronic Health Record (EHR) with post-operative outcomes for nonemergency surgeries. DESIGN: Retrospective cohort study. SETTING: Academic Medical Center. PARTICIPANTS: Patients 65 years or older that underwent nonemergency surgery with an inpatient stay 24 hours or more between October 8th, 2017 and June 1st, 2019. EXPOSURES: Frailty as measured by a 54-item electronic frailty index (eFI). OUTCOMES AND MEASUREMENTS: Inpatient length of stay, requirements for post-acute care, 30-day readmission, and 6-month all-cause mortality. RESULTS: Of 4,831 unique patients (2,281 females (47.3%); mean (SD) age, 73.2 (5.9) years), 4,143 (85.7%) had sufficient EHR data to calculate the eFI, with 15.1% categorized as frail (eFI > 0.21) and 50.9% pre-frail (0.10 < eFI ≤ 0.21). For all outcomes, there was a generally a gradation of risk with higher eFI scores. For example, adjusting for age, sex, race/ethnicity, and American Society of Anesthesiologists class, and accounting for variability by service line, patients identified as frail based on the eFI, compared to fit patients, had greater needs for post-acute care (odds ratio (OR) = 1.68; 95% confidence interval (CI) = 1.36-2.08), higher rates of 30-day readmission (hazard ratio (HR) = 2.46; 95%CI = 1.72-3.52) and higher all-cause mortality (HR = 2.86; 95%CI = 1.84-4.44) over 6 months' follow-up. CONCLUSIONS: The eFI, an automated digital marker for frailty integrated within the EHR, can facilitate pre-operative frailty screening at scale.

The Electronic Health Record Objective Structured Clinical Examination Station: Assessing Student Competency in Patient Notes and Patient Interaction.

Introduction: The ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter. Methods: Of third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan. Results: Training SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = -12.4, p <.001. Discussion: The EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

Educational priorities of students in the entrustable professional activity era.

BACKGROUND: The Association of American Medical Colleges (AAMC) guidelines on the entrustable professional activities (EPAs) expected of graduating medical students were recently published. Although perceptions of educators, residents and programme directors have been described, the voice of senior medical students is lacking. METHODS: A single-institution cross-sectional study of senior medical students was performed. Student perceptions were collected and compared with: (1) national guidelines (i.e. the 13 newly developed undergraduate EPAs); (2) resident expectations (i.e. through comparison with a recently published survey from >28 000 residents); and (3) institutional objectives. Descriptive statistics were performed. RESULTS: A total of 113 students participated. The top three EPA-based educational priorities were 'recognising a patient requiring urgent/emergent care' (EPA10), 'performing procedures of a physician' (EPA12) and 'collaborating as an interprofessional' (EPA9). Over 80 per cent of students rated 'managing time efficiently' and 'communicating around care transitions' as very important pre-internship skills. Of the institutional objectives, 87 per cent rated 'recognising critically ill patients' and 'knowing when to ask for help' as the most important pre-internship skills. The voice of senior medical students is lacking CONCLUSIONS: Although the emphasis on knowing when to ask for help and communication around care transitions differed somewhat across stakeholders, educational priorities were shared by students, residents, educators and institutional objectives. These preliminary data support national assessments of perceptions and achievements of senior medical students to guide residency readiness in the EPA era.

Comparative evaluation of adhesion formation, strength of ingrowth, and textile properties of prosthetic meshes after long-term intra-abdominal implantation in a rabbit.

BACKGROUND: Effective laparoscopic ventral herniorrhaphy usually mandates the use of an intraperitoneal prosthetic. Visceral adhesions and changes in textile characteristics of prosthetics may complicate repairs, especially long-term. The aim of this study was to compare the adhesion formation, tissue ingrowth, and textile characteristics one year after intra-abdominal placement of the commonly used prosthetic meshes. MATERIALS AND METHODS: Forty (4 x 4 cm) meshes were sutured using absorbable suture to an intact peritoneum in 20 New Zealand white rabbits. The study groups included: polypropylene (PP) [Marlex; C.R. Bard Inc, Cranston, NJ], expanded polytetrafluoroethylene (ePTFE) [DualMesh; WL Gore, Flagstaff, AZ], ePTFE and PP (ePTFE/PP) [Composix, C.R. Bard Inc], reduced weight PP and oxidized regenerated cellulose (rPP/C) [Proceed; Ethicon, Inc, Somerville, NJ]. The meshes were explanted after one year. Adhesions were scored as a percentage of explanted biomaterials' affected surface area. Prosthetic shrinkage was calculated. The strength of incorporation and mesh compliance were evaluated using differential variable reluctance transducers. Mesh ingrowth was measured as the load necessary to distract the mesh/tissue complex. Mesh compliance was calculated as the change in linear displacement of the sensors due to applied load. The groups were compared using Student's t-test and Fisher's exact test. RESULTS: ePTFE had significantly less adhesions (0%) than both ePTFE/PP (40%) and PP (80%) groups (P < 0.001). The mean area of adhesions for the rPP/C (10%) and the ePTFE/PP (14%) groups was less than that for the PP group (40%) (P = 0.02). Prosthetic shrinkage was greatest in the ePTFE (32%) group than in any other group (P = 0.001). There were no differences in mesh incorporation between the groups. At explantation, mesh compliance in the ePTFE group was superior to other meshes (P < 0.0001). The rPP/C mesh induced the smallest change in the compliance of the tissue adjacent to the mesh (P = 0.0001). CONCLUSIONS: Prosthetic materials demonstrate a wide variety of characteristics. Although exposed PP formed the most adhesions, up to 40% of the other PP-based meshes formed adhesions despite protective barriers. The ePTFE mesh did not induce adhesions and was the most compliant, however, this prosthetic's contraction was greatest. Reduced weight polypropylene (rPP/C) mesh induced the smallest change in the adjacent tissue pliability/compliance. Understanding of the long-term effects of various prosthetic materials is important to ensure an adequate hernia repair while minimizing postoperative morbidity and patient discomfort.

Prospective histologic evaluation of intra-abdominal prosthetics four months after implantation in a rabbit model.

BACKGROUND: Placement of an intraperitoneal prosthetic is required for laparoscopic ventral hernia repair. The biocompatibility of these prosthetics determines the host's inflammatory response, scar plate formation, tissue ingrowth, and subsequent mesh performance, including prosthetic compliance and prevention of hernia recurrence. We evaluated the host response to intraperitoneal placement of several prosthetics currently used in clinical practice. METHODS: A 4-cm x 4-cm piece of mesh was implanted on intact peritoneum in New Zealand white rabbits. The mesh types included expanded polytetrafluoroethylene (ePTFE) (DualMesh), ePTFE and polypropylene (Composix, heavyweight polypropylene), polypropylene and oxidized regenerated cellulose (Proceed, midweight polypropylene), and polypropylene (Marlex, heavyweight polypropylene). At four months, standard hematoxylin and eosin and Milligan's trichrome stains of the mesh-tissue interaction were analyzed by three observers blinded to the mesh types. Each specimen was evaluated for scar plate formation, inflammatory response, and tissue ingrowth. Each of these three categories was graded on a standard scale of 1-4 (1 = normal tissue and 4 = severe inflammatory response). The scores were analyzed using Wilcoxon rank sum test with p < 0.05 as significant. RESULTS: Ten samples of each mesh type were evaluated. There was no difference in tissue incorporation between the groups. The mean scar plate formation was greater in the heavyweight polypropylene meshes than for DualMesh (p = 0.04). With Proceed, the reduction in scar plate formation compared with that for Composix and Marlex approached statistical significance (p = 0.07). The mean number of inflammatory cells was greater around the ePTFE when compared with the midweight polypropylene (p = 0.02) but equal to the other meshes. CONCLUSIONS: The four prosthetic materials evaluated in this study demonstrate comparable host biocompatibility as evidenced by the tissue ingrowth. Scar plate formation around DualMesh was significantly less than that around Composix and Marlex. Interestingly, more inflammatory cells were noted surrounding the DualMesh which was equal to that of the heavyweight meshes. Proceed, a midweight polypropylene mesh, has the potential for improved patient tolerance compared to heavyweight polypropylene meshes based on its favorable histologic findings.

Retained foreign bodies after surgery.

BACKGROUND: Medical errors during surgery are not well studied. To define risk factors associated with this type of error, we performed a case control analysis. METHODS: We retrospectively reviewed medical records involving the ICD-9 code (998.4) for unintentional foreign object remaining in the body during surgery and incident reports gathered by the Department of Risk Management over a 10 year period from 1996 to 2005. Thirty cases were matched with at least four randomly selected controls (131 control patients) that underwent the same type of operation during the same time period. RESULTS: Thirty patients had retained foreign objects (52% sponges and 43% instruments). The abdominal cavity was most commonly involved (46%) followed by the thoracic cavity (23%) although no body cavity remained uninvolved. Eight patients required readmission (30%), 25 patients required reoperation (83%), and there was no mortality. When compared with controls, patients with retained foreign objects were more likely to have had a greater number of major surgical procedures at the same time (2.7 versus 1.8, P=0.004), to have multiple surgical teams (13% versus 2%, P=0.02), and more likely to have had an incorrect instrument/sponge count recorded (13% versus 2%, P=0.01). In multivariate analysis, factors associated with a significantly higher risk of retained foreign objects were the total number of major procedures performed [odds ratio 1.6; 95% confidence interval (CI), 1.1-2.3; P=0.008] and an incorrect count (odds ratio 16.2; 95% CI, 1.3-197.8; P=0.02). CONCLUSION: Retained foreign objects after surgery are associated with multiple major surgical procedures being performed at the same time and an incorrect instrument or sponge count. Identification of these risk factors using case-control analysis should influence operating room policy and reduce these types of errors.

Prospective evaluation of adhesion formation and shrinkage of intra-abdominal prosthetics in a rabbit model.

Laparoscopic ventral hernia repair requires an intraperitoneal prosthetic; however, these materials are not without consequences. We evaluated host reaction to intraperitoneal placement of various prosthetics and the functional outcomes in an animal model. Mesh (n = 15 per mesh type) was implanted on intact peritoneum in New Zealand white rabbits. The mesh types included ePTFE (DualMesh), ePTFE and polypropylene (Composix), polypropylene and oxidized regenerated cellulose (Proceed), and polypropylene (Marlex). Adhesion formation was evaluated at 1, 4, 8, and 16 weeks using 2-mm mini-laparoscopy. Adhesion area, adhesion tenacity, prosthetic shrinkage, and compliance were evaluated after mesh explantation at 16 weeks. DualMesh had significantly less adhesions than Proceed, Composix, or Marlex at 1, 4, 8, and 16 weeks (P < 0.0001). Marlex had significantly more adhesions than other meshes at each time point (P < 0.0001). There were no statistically significant differences in adhesions between Proceed and Composix meshes. After mesh explantation, the mean area of adhesions for Proceed (4.6%) was less than for Marlex (21.7%; P = 0.001). The adhesions to Marlex were statistically more tenacious than the DualMesh and Composix groups. Overall prosthetic shrinkage was statistically greater for DualMesh (34.7%) than for the remaining mesh types (P < 0.01). Mesh compliance was similar between the groups. Prosthetic materials demonstrate a wide variety of characteristics when placed inside the abdomen. Marlex formed more adhesions with greater tenacity than the other mesh types. DualMesh resulted in minimal adhesions, but it shrank more than the other mesh types. Each prosthetic generates a varied host reaction. Better understanding of these reactions can allow a suitable prosthetic to be chosen for a given patient in clinical practice.