Development and content validation of the checklist for assessing placement of a small-bore chest tube (CAPS) for small-bore chest tube placement.

Background: Small-bore chest tube (SBCT) placement via modified Seldinger technique is a commonly performed invasive procedure for treatment of pleural effusion and pneumothorax. When performed suboptimally, it may lead to serious complications. Validated checklists are central to teaching and assessing procedural skills and may result in improved health care quality. In this paper, we describe the development and content validation of a SBCT placement checklist. Methods: A literature review across multiple medical databases and seminal textbooks was performed to identify all publications describing procedural steps involved in SBCT placement. No studies were identified that involved systematic development of a checklist for this purpose. After the first iteration of a comprehensive checklist (CAPS) based on literature review was developed, the modified Delphi technique involving a panel of nine multidisciplinary experts was used to modify it and establish its content validity. Results: After four Delphi rounds, the mean expert-rated Likert score across all checklist items was 6.85 ± 0.68 (out of 7). The final, 31-item checklist had a high internal consistency (Cronbach's alpha = 0.846) with 95% of the responses (by nine experts across 31 checklist items) being a numerical score of 6 or 7. Conclusions: This study reports the development and content validity of a comprehensive checklist for teaching and assessing SBCT placement. For purposes of demonstrating construct validity, this checklist should next be studied in the simulation and clinical setting.

Incoming Interns Recognize Inadequate Physical Examination as a Cause of Patient Harm.

INTRODUCTION: As providers of a large portion of the care delivered at academic health centers, medical trainees have a unique perspective on medical error. Despite data suggesting that errors in physical examination (PE) can lead to adverse patient events, we are not aware of previous studies exploring medical trainee perceptions of the relationship between patient harm and inadequate PE. We investigated whether first-year residents at a large tertiary care academic medical center perceive inadequate PE as a cause of adverse patient events. METHODS: As part of a larger survey given to incoming interns at Thomas Jefferson University Hospital orientation (2014-2018), the authors examined the perceptions of inadequate PE and adverse patient events. We also examined other details related to PE educational experiences and self-reported PE proficiency. The survey was developed a priori by the authors and assessed for face validity by expert faculty. RESULTS: Ninety-eight percent of respondents (695/706) reported that inadequate PE leads to adverse patient events. Seventy percent (492/706) believe that inadequate PE causes adverse events in up to 10% of all patient encounters, and 30% (214/706) reported that inadequate PE causes adverse events in greater than 10% of patient encounters. Forty-five percent of surveyed interns (319/715) had witnessed a patient safety issue as a result of an inadequate PE. Only 2% of surveyed interns (11/706) did not think patients experience adverse events because of inadequate PEs. Ninety percent of surveyed interns (643/712) reported feeling proficient in performing PE. From 2015 to 2018, 80% (486/604) indicated that they received "just enough" PE education. CONCLUSION: Nearly all incoming interns surveyed at our institution believe that inadequate PE leads to adverse patient events, and 45% have witnessed an adverse patient event due to inadequate PE. We urge clinicians, educators, and health care administrators to consider enhanced PE skills training as an important and viable approach to medical error reduction, and as such, we propose a 5-pronged intervention for improvement, including a redesign of PE curricula, development of checklist-based assessment methods, ongoing skills training and assessment of physicians-in-practice, rigorous study of PE maneuvers, and research into whether enhanced PE skills improve patient outcomes.

Identifying Students at Risk of Failing the USMLE Step 2 Clinical Skills Examination.

BACKGROUND AND OBJECTIVES: New standards announced in 2017 could increase the failure rate for Step 2 Clinical Skills (CS). The purpose of this study was to identify student performance metrics associated with risk of failing. METHODS: Data for 1,041 graduates of one medical school from 2014 through 2017 were analyzed, including 30 (2.9%) failures. Metrics included Medical College Admission Test, United States Medical Licensing Examination Step 1, and clerkship National Board of Medical Examiners (NBME) Subject Examination scores; faculty ratings in six clerkships; and scores on an objective structured clinical examination (OSCE). Bivariate statistics and regression were used to estimate risk of failing. RESULTS: Those failing had lower Step 1 scores, NBME scores, faculty ratings, and OSCE scores (P<.02). Students with four or more low ratings were more likely to fail compared to those with fewer low ratings (relative risk [RR], 12.76, P<.0001). Logistic regression revealed other risks: low surgery NBME scores (RR 3.75, P=.02), low pediatrics NBME scores (RR 3.67, P=.02), low ratings in internal medicine (RR 3.42, P=.004), and low OSCE Communication/Interpersonal Skills (RR 2.55, P=.02). CONCLUSIONS: Certain medical student performance metrics are associated with risk of failing Step 2 CS. It is important to clarify these and advise students accordingly.

Patient Handoff Education: Are Medical Schools Catching Up?

Communication errors during shift-to-shift handoffs are a leading cause of preventable adverse events. Nevertheless, handoff skills are variably taught at medical schools. The authors administered questionnaires on handoffs to interns during orientation. Questions focused on medical school handoff education, experiences, and perceptions. The majority (546/718) reported having some form of education on handoffs during medical school, with 48% indicating this was 1 hour or less. Most respondents (98%) reported that they believe patients experience adverse events because of inadequate handoffs, and more than one third had witnessed a patient safety issue. Results show that medical school graduates are not receiving adequate handoff training. Yet graduates are expected to conduct safe patient handoffs at the start of residency. Given that ineffective handoffs pose a significant patient safety risk, medical school graduates should have a baseline competency in handoff skills. This will require medical schools to develop, implement, and study handoff education.

Higher postmortem prefrontal 5-HT2A receptor binding correlates with lifetime aggression in suicide.

BACKGROUND: In vivo studies find altered serotonin function associated with aggressive and suicidal behaviors. Postmortem studies also reveal serotonergic alterations in suicide subjects but have not reported on the relationship between aggression and the serotonin system. We measured 5-hydroxytryptamine 2A (5-HT(2A)) receptor binding in prefrontal cortex of suicide and nonsuicide subjects and explored the relationship between 5-HT(2A) receptor binding, lifetime aggression, and suicide. METHODS: The 5-HT(2A) receptor binding in coronal sections of prefrontal cortex was quantified by autoradiography with [(3)H] ketanserin in 37 suicide subjects and 73 nonsuicide subjects. The relationship between [(3)H] ketanserin binding and lifetime aggression, rated on the Brown-Goodwin Aggression History Scale, was assessed controlling for age and sex. RESULTS: In suicide subjects, lifetime aggression scores correlated positively with [(3)H] ketanserin binding in all prefrontal Brodmann areas examined, after adjusting for age and sex. This was not the case in nonsuicide subjects. We found no significant differences in aggression scores or [(3)H] ketanserin binding between the suicide subjects and nonsuicide subjects. CONCLUSIONS: The relationship between aggression and 5-HT(2A) receptor binding in suicide subjects, but not in nonsuicide subjects, may reflect differences in the regulation of the 5-HT(2A) receptor related to suicidal behavior and perhaps other proaggressive changes in brains of suicide subjects.

Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder.

OBJECTIVE: The authors investigated the predictive potential of a stress-diathesis model for suicidal behavior based on correlates of past suicidal acts. In this model, suicidal acts are precipitated by stressors such as life events or a major depressive episode in the setting of a propensity for acting on suicidal urges. This diathesis is expressed as the tendency to develop more pessimism in response to a stressor and/or the presence of aggressive/impulsive traits. The predictive potential of the diathesis was tested by determining whether clinical correlates of past suicidal behavior predict suicidal acts during a 2-year follow-up of patients with a major depressive episode. METHOD: Patients with DSM-III-R major depressive disorder or bipolar disorder (N=308) were assessed at presentation for treatment of a major depressive episode. Potential predictors of suicidal acts in the 2 years after study enrollment were identified on the basis of an association with previous suicidal behavior and were tested by using Cox proportional hazards regression analysis. In addition, pessimism and aggression/impulsivity factors were generated, and their predictive ability was tested by using Cox proportional hazards regression analysis. RESULTS: The three most powerful predictors of future suicidal acts were a history of suicide attempt, subjective rating of the severity of depression, and cigarette smoking, each of which had an additive effect on future risk. The pessimism and aggression/impulsivity factors both predicted suicidal acts, and each factor showed an additive effect. CONCLUSIONS: In addition to obtaining a history of suicidal behavior, clinicians may find it useful to assess patients' current level of pessimism, aggressive/impulsive traits, and comorbidity with substance use disorders, including nicotine-related disorders, to help identify patients at risk for suicidal behavior after major depression. Interventions such as aggressive pharmacotherapeutic prophylaxis to prevent relapse or recurrence of depressive symptoms may protect such at-risk individuals from future suicidal behavior.

Electronic support groups for breast carcinoma: a clinical trial of effectiveness.

BACKGROUND: A recent Pew Charitable Trust study found that 52,000,000 individuals used the Internet to obtain health/medical information. Clinical trials of face-to-face breast carcinoma support groups show evidence of 1) improvement in quality of life, 2) reduction of psychologic symptoms, 3) improvement in coping responses, and 4) a reduction in pain. To the authors' knowledge, a few studies published to date have investigated Internet-delivered electronic support groups (ESGs) for cancer. The most sophisticated is the Comprehensive Health Enhancement Support System (CHESS) program, which provides integrated information, referral, and a newsgroup-based social support program. However, to the authors' knowledge, no studies published to date have examined the impact of a breast carcinoma ESG in a clinical trial. METHODS: Sixty-seven women completed the initial baseline questionnaires, 32 of whom accepted the authors' invitation and began the groups. With regard to geographic location, 49% lived in rural/small towns, 41% lived in medium-sized cities, and 10% lived in large cities. Diagnostic stages of disease were: Stage I, 22%; Stage II, 56%; Stage III, 12%; and other forms, 10%. There were 4 intervention groups, of which 8 participants led by trained Wellness Community (TWC) (a national agency) leaders met for 1.5 hours once a week for 16 weeks. Student t tests for paired outcome data were computed using baseline and postgroup scores. RESULTS: The results of the current study indicated that breast carcinoma patients significantly reduced depression (Center for Epidemiologic Studies-Depression [CES-D] scale) and Reactions to Pain. They also demonstrated a trend toward increases on The Posttraumatic Growth Inventory (PTGI) in two subscales: New Possibilities and Spirituality. Counterintuitively, breast carcinoma patients appeared to demonstrate an increase in emotional suppression. Postinterview results indicated that approximately 67% of patients found the group to be beneficial. Those who withdrew from the groups (20%) demonstrated low scores in their ability to contain anxiety and appeared to be more likely to suppress their thoughts and feelings regarding their illness. CONCLUSIONS: The findings of the current study are encouraging, particularly because it was conducted through TWC, a national agency willing to make this type of intervention readily available at no cost. A limitation of the current study was the lack of randomization and a control group comparison. Although the authors were not able to demonstrate effectiveness without the addition of a control condition, the analysis of pregroup and postgroup outcomes suggests that a randomized trial is worthwhile. Women with a devastating disease will join and commit themselves to an online support group. In addition, because a large percentage of these women were from rural locations, this type of intervention may hold promise for those who have limited access to support groups.