Clinical Reasoning: Perspectives of Expert Clinicians on Reasoning Through Complex Clinical Cases.

Introduction Clinical reasoning is a core skill for physicians; most doctors do not attain the level of expertise associated with that of an expert clinician (EC). The purpose of this study is to identify the clinical reasoning strategies ECs prioritize when reasoning through complex cases. Methods We interviewed 14 ECs and performed a thematic analysis to identify strategies ECs prioritize when reasoning through complex clinical cases. The authors chose ECs based on the recognition of clinical and teaching expertise by trainees and other faculty members (ECs within our institution) and institutional recognition of high achievement in medicine and medical education (ECs outside our institution). We used a semi-structured guide to interview each EC, then reviewed and coded the interview transcriptions. We developed themes based on agreements between all transcript reviewers.  Results We interviewed 11 male and three female ECs, one from outside the study institution. Two (14%) ECs were primary care physicians, and the remaining were sub-specialists. The authors organized strategies for clinical reasoning through complex cases around four themes, which were as follows: (1) connecting clinical reasoning to patient context; (2) embracing uncertainty, then reducing it; (3) returning to the patient's bedside; and (4) remaining humble to limit diagnostic errors. Conclusion Clinical reasoning is a core clinical skill of physicians, and this article describes clinical reasoning strategies prioritized by ECs for complex clinical cases. Recognition and integration of these strategies into medical training and clinical educator practice may facilitate the evolution of clinical reasoning skills and reduce diagnostic errors.

Strategies to Improve Teaching Point-of-Care Ultrasound at the Bedside.

Point-of care-ultrasound (POCUS) is becoming a core clinical skill in many medical specialties. Teaching POCUS at the bedside allows for observation of learners during actual patient encounters, provides a medium for role modeling skills and behaviors, and incorporates all core POCUS competencies. Nonetheless, bedside teaching can be time consuming and intimidating for learners and teachers, and the full benefits of teaching at the bedside can be difficult to attain. We provide strategies for improving bedside POCUS teaching based on our collective experience as medical educators and POCUS instructors at both the undergraduate and graduate levels in medical education.

Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics.

BACKGROUND: At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. OBJECTIVE: To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. PARTICIPANTS: General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. MAIN MEASURE: An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). KEY RESULTS: Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. CONCLUSIONS: Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.

Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation.

Reflective practice is essential for the ongoing maturation of clinicians and requires regular self-evaluation in association with ongoing mentoring and feedback. Currently, most resident physicians do not have access to educational experiences that fulfill these needs. We present a novel model for structured one-on-one longitudinal coaching using the principles of deliberate practice to improve diagnostic skills. This is an easily implementable educational model that can be replicated in residencies across the country to improve clinical reasoning. Skills learned through this program have the potential not only to bolster the academic approach to patients but to also directly improve the clinical assessment and care of patients under the trainee's care.

Structured interdisciplinary bedside rounds improve interprofessional communication and workplace efficiency among residents and nurses on an inpatient internal medicine unit.

Structured Interdisciplinary Bedside Rounds (SIBR) is a standardized, team-based intervention for hospitals to deliver high quality interprofessional care. Despite its potential for improving IPC and the workplace environment, relatively little is known about SIBR's effect on these outcomes. Our study aimed to assess the fidelity of SIBR implementation on an inpatient medicine teaching unit and its effects on perceived IPC and workplace efficiency. We conducted a quasi-experimental study with 88 residents and 44 nurses at a large academic medical center and observed 1308 SIBR encounters over 24 weeks. Of these 1308 encounters, the bedside nurse was present for 96.7%, physician for 97.6%, and care manager for 94.7, and 64.7% occurred at the bedside. Following SIBR implementation, perceived IPC improved significantly among residents (93.3% versus 67.9%, p < .024) and nurses (73.7% versus 36.0%, p < .008) compared to before implementation. Moreover, residents perceived greater workplace efficiency operationalized as being paged less frequently with questions by nurses (20.0% versus 49.1%, p = .01). No statistically significant improvements were reported regarding burnout, meaning at work, and workplace satisfaction. Our implementation of SIBR significantly improved perceived IPC and workplace efficiency, which are two important domains of healthcare quality. Future work should examine the impact of SIBR on patient-centered outcomes such as patient experience.

Training to Cure-Implementing a Hepatitis C Clinic Curriculum in Primary Care Residency Training.

BACKGROUND: Residents lack exposure to chronic hepatitis C (HCV) infection management, limiting the pipeline of providers able to alleviate the treatment bottleneck. ACTIVITY: We surveyed 34 residents rotating through a new HCV curriculum comprised of a clinic primer, didactics, and supervised patient care. Outcome measures were knowledge and self-efficacy regarding HCV management. RESULTS: HCV knowledge scores improved significantly from 58% pre-clinic to 76% immediately post (p < 0.001)- and 66% 3-month post-clinic (p = 0.006). Residents felt more confident managing HCV after the clinic rotation. DISCUSSION: Our clinic curriculum is feasible, improves knowledge regarding HCV, and is a unique approach to preparing physicians to cure HCV.

Patients' Perceptions of Bedside Rounding.

OBJECTIVES: Concerns regarding lack of privacy, poor patient understanding, and physician discomfort have led to a decline in rounding at the bedside. Our project explored patient perceptions of the implementation and value of bedside rounding. METHODS: This mixed-methods study used semi-structured qualitative interviews and a five-item Likert survey, which included questions about patients' experiences with rounds, their comfort level with the rounding process, and their understanding of care after rounds. Interviews were analyzed using the constant comparative method and conducted until thematic saturation occurred. RESULTS: Patients described positive attributes of bedside rounds: meeting the medical team, helping teach the medical team, and understanding more about their illness. Although patients enjoyed undivided attention from physicians, distractions included too many participants in rounds, confusion about roles, and unclear expectations about the goal of rounds. Although physicians sought to use patient-centered language, 53% of patients stated that medical jargon was still used. Male patients reported a statistically significant improvement in their understanding about the plan for the day and borderline significance regarding knowing who was responsible for their care as compared with female patients. CONCLUSIONS: Well-conducted, patient-centered bedside rounds greatly enhance patient-physician rapport and foster patient understanding and satisfaction.

An International Collaboration for the Training of Medical Chief Residents in Rwanda.

BACKGROUND: The year-long position of chief medical resident is a time-honored tradition in the United States that serves to provide the trainee with an opportunity to gain further skills as a clinician, leader, teacher, liaison, and administrator. However, in most training programs in the developing world, this role does not exist. OBJECTIVES: We sought to develop a collaborative program to train the first medical chief residents for the University of Rwanda and to assess the impact of the new chief residency on residency training, using questionnaires and qualitative interviews with Rwandan faculty, chief residents, and residents. METHODS: The educational context and the process leading up to the appointment of Rwandan chief residents, including selection, job description, and necessary training (in the United States and Rwanda), are described. One year after implementation, we used a parallel, mixed methods approach to evaluate the new chief medical resident program through resident surveys as well as semistructured interviews with key informants, including site chief residents, chief residents, and faculty. We also observed chief residents and site chief residents at work and convened focus groups with postgraduate residents to yield additional qualitative information. RESULTS: Rwandan faculty and residents generally felt that the new position had improved the educational and administrative structure of the teaching program while providing a training ground for future academicians. CONCLUSIONS: A collaborative training program between developing and developed world academic institutions provides an efficient model for the development of a new chief residency program in the developing world.

Resident and Faculty Perceptions of Chart-Stimulated Recall.

OBJECTIVES: Chart-stimulated recall (CSR) is a case-based interviewing technique advocated by the Accreditation Council for Graduate Medical Education as an assessment tool across a variety of clinical competencies, yet resident and faculty perceptions of this exercise have not been reported previously. The authors incorporated a CSR exercise into an internal medicine residency program and sought to assess the perceptions of residents and faculty participants. METHODS: Faculty met weekly with night float residents at the end of their shift. The resident presented verbally while the faculty reviewed his or her written note. In the course of 3 years, 7 faculty and 73 residents participated. Participating residents completed an anonymous survey at the end of each academic year and faculty underwent a semistructured interview administered by the authors. RESULTS: A total of 73% of resident respondents believed that CSR was a valuable component of the night float rotation and should be continued. Faculty believed that the exercise allowed time for focused teaching of the night team, who otherwise received limited formal instruction. The most common critique of the sessions was the timing, because the residents often reported feeling too tired to engage actively in the sessions. CONCLUSIONS: CSR was easy to implement, received well, and educationally valued by both residents and faculty. Participants viewed the exercise as useful for both teaching and formative assessment.

Improvement of medical education through the establishment of a medical chief resident position in Rwanda

Background: The Chief Medical Resident (CMR) role is a well established, one-year position that has existed in the United States (US) for many years. Through collaboration between Yale University Primary Care Internal Medicine Residency Program and the University of Rwanda/College of Medicine and Health Sciences, the Internal Medicine Residency Program in Rwanda began a collaborative training program for Rwandan medical chief residents two years ago. Aims:This paper describes the selection and collaborative training process of the new Rwandan CMRs in teaching hospitals in Rwanda. We also report on evaluation of the role, its impact, and evolving challenges from the perspectives of the current residents through a quantitative survey. Methodology: A survey was directed to residents of the Internal Medicine residency training program. The survey was conducted at the two tertiary teaching sites in Rwanda: Butare University Teaching Hospital (CHUB) and Kigali University Teaching Hospital (CHUK) where chief residents are assigned. On a Likert scale, a group of continuing residents were asked to grade items assessing a change in several educational aspects. The second group of residents, which consisted of first-year residents, was mainly asked questions directed at describing their perception on the chief resident role. Results: In total, 38 residents out of the 40 at the two tertiary hospitals took the survey. Of the 38 residents who took the survey,74% of respondents agreed or strongly agreed on the statement about improvement in educational conferences. 69.6 % of residents noted an improvement in medical education due to having a chief resident in the program. An overall improvement of the residency training program was observed by 78.3% of our study participants. In general (73.7%), residents perceive chief residents as their role model, with first-year residents (100%) being the most enthusiastic about this statement. Conclusion: The chief resident role establishment has made a positive impact in medical education in Internal Medicine/ University of Rwanda. Chief residents play a big role in medical education and are regarded as role models by their fellow residents

Discharge Rounds: Implementation of a Targeted Intervention for Improving Patient Throughput on an Inpatient Medical Teaching Service.

OBJECTIVES: Patient throughput and early discharges are important for decreasing emergency department wait times and creating available beds for new hospital admissions. The educational schedule of internal medicine trainees can interfere with timely discharges, but targeted interventions can help residents meet the hospital's patient flow needs. Our training program instituted daily morning discharge rounds on the inpatient service, requiring each team to prepare potential discharges 1 day ahead and prioritizing these discharges the next day. METHODS: We conducted a retrospective, pre-post analysis 1 month before and 3 months after implementation in August 2013 to assess discharge order entry times, the proportion of discharges before 11:00 am, and hospital departure times. RESULTS: One month post-implementation, discharge orders were entered 59 minutes earlier (from 1:07 pm to 12:08 pm; P = 0.001), the percentage of pre-11:00 am discharges increased from 21% to 39% (P < 0.01), and patients departed the hospital 50 minutes earlier (from 3:21 pm to 2:31 pm; P = 0.005). These effects, however, returned to pre-implementation times during the subsequent 2 months. CONCLUSIONS: A targeted intervention can significantly improve early discharges and should be replicable at other academic medical centers. Reinforcement is needed for these gains to be sustainable, however.

On Medicaid and the Affordable Care Act in Connecticut: the problem with subspecialty services.

BACKGROUND: Medicaid is the federal program, administered by states, for health care for the poor. The Affordable Care Act (ACA) has added a large number of new recipients to this program. HYPOTHESIS: Medicaid programs in some, if not many, states do not provide patients uniform access to subspecialty care guaranteed by the federal statutes. Insofar as the ACA does not address this pre-existing "sub-specialty gap" and more patients are now covered by Medicaid under the ACA, the gap is likely to increase and may contribute to disparities of health care access and outcomes. METHODS: A brief description of previous studies demonstrating or suggesting a subspecialty gap in Medicaid services is accompanied by perspectives of the authors, using published literature - most notably the Denver, Colorado health care system - to propose various solutions that may be deployed to address gaps in subspecialty coverage. RESULTS: All published studies describing the Medicaid subspecialty gap are qualitative, survey designs. There are no authoritative objective data regarding the exact prevalence of gaps for each subspecialty in each state. However, surveys of caregivers suggest that gaps were prevalent in the United States prior to initiation of the ACA. Even fewer papers have addressed solutions (in light of the paucity of data describing the magnitude of the problem), and proposed solutions remain speculative and not grounded in objective data. CONCLUSIONS: There is reason to believe that a substantial proportion of U.S. citizens - those who are guaranteed a full complement of health services through Medicaid - have difficult or no access to some subspecialty services, many of which other citizens take for granted. This problem deserves greater attention to verify its existence, quantify its magnitude, and develop solutions.

Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE).

BACKGROUND: The Accreditation Council for Graduate Medical Education and American Board of Internal Medicine have identified cost-awareness as an important component to residency training. Cost-awareness is generally not emphasized in current, traditional residency curricula despite the recognized importance of this topic. DESCRIPTION: Using a traditional Morning Report structure and actual charge data from our institution, the charges associated with trainee-directed workup of clinical cases are compared in a friendly competition among medical students, interns, residents, and faculty. EVALUATION: Anonymous, voluntary survey of all participants and comparison of expenditures by training level were used to assess this pilot program. The educational quality of the I-CARE was rated higher than the prior format of Morning Report by participants (10-point Likert scale; 8.57, 6.81 respectively; p < .001). Open-ended comments were overwhelmingly supportive from faculty and trainees. Cost was lower for attending physicians than for trainees ($1,027.45 vs. $4,264.00, p = .02) and diagnostic accuracy was also highest for attending physicians. CONCLUSIONS: The I-CARE is easy and quick to implement, and the preliminary results show a popular cost-awareness educational experience for internal medicine trainees. Further study is needed to determine change in practice habits.

Complementary and alternative medicine use in chronic liver disease patients.

GOALS: To examine a wide range of sociodemographic and clinical characteristics as potential predictors of complementary and alternative medicine (CAM) use among chronic liver disease (CLD) patients, with a focus on CAM therapies with the greatest potential for hepatotoxicity and interactions with conventional treatments. BACKGROUND: There is some evidence that patients with CLD commonly use CAM to address general and CLD-specific health concerns. STUDY: Patients enrolled in a population-based surveillance study of persons newly diagnosed with CLD between 1999 and 2001 were asked about current use of CAM specifically for CLD. Sociodemographic and clinical information was obtained from interviews and medical records. Predictors of CAM use were examined using univariate and multivariate logistic regression analysis. RESULTS: Of the 1040 participants, 284 (27.3%) reported current use of at least 1 of 3 CAM therapies of interest. Vitamins or other dietary supplements were the most commonly used therapy, reported by 188 (18.1%) patients. This was followed by herbal medicine (175 patients, 16.8%) and homeopathy (16 patients, 1.5%). Several characteristics were found to be independent correlates of CAM use: higher education and family income, certain CLD etiologies (alcohol, hepatitis C, hepatitis C and alcohol, and hepatitis B), and prior hospitalization for CLD. CONCLUSIONS: Use of CAM therapies that have the potential to interact with conventional treatments for CLD was quite common among this population-based sample of patients with CLD. There is a need for patient and practitioner education and communication regarding CAM use in the context of CLD.

The epidemiology and clinical characteristics of patients with newly diagnosed alcohol-related liver disease: results from population-based surveillance.

GOALS: We describe the epidemiology of outpatients newly diagnosed with chronic alcoholic liver disease and describe predictors of cirrhosis and referral for specialty care. BACKGROUND: Alcohol is a major cause of liver disease in the United States. Most previous work has described hospitalized patients. STUDY: Participants were identified through prospective population-based surveillance in gastroenterology practices Multnomah County, Oregon and New Haven County, Connecticut; and primary care and gastroenterology practices from Kaiser Permanente Northern California in Alameda County during 1999 to 2001. Patients were interviewed, a blood specimen obtained, and their medical record reviewed. RESULTS: We identified 82 patients from gastroenterology practices with newly diagnosed alcoholic liver disease. Their median age was 50.0 years. 72.0% were male and 79.3% were White. The median age at initiation of alcohol use was 17.0 years. 43.9% of patients had evidence of cirrhosis at the time of diagnosis. Only 40.2% reported alcohol as the cause of their liver disease. Patients with cirrhosis were more likely to be older, have a higher median number of years of heavy alcohol consumption, and to have been hospitalized for a liver-related complication than noncirrhotic patients. An additional 83 primary care patients were more likely to be older, to be drinking alcohol at study interview, and to not have cirrhosis than patients referred for gastroenterology care. CONCLUSIONS: Patients with alcoholic liver disease may present at a late stage and may not identify alcohol as a cause for their liver disease. Improved patient screening and education may limit morbidity and mortality.

Use of fax-back surveillance to determine epidemiologic and clinical characteristics of patients diagnosed with hepatitis C in Waterbury, Connecticut.

Hepatitis C (HCV) is a leading cause of chronic liver disease in the United States. Connecticut has a registry of laboratory reported cases of HCV. These reports include limited patient-level information. Using a one-page abstraction instrument, we used this registry to contact providers by fax to obtain contact, epidemiologic, and clinical information on Waterbury residents with newly reported HCV. We offered to perform the data abstraction if desired by the physician. In 2004, 376 new cases of HCV were reported. Eighty-eight percent of abstraction instruments were returned; most were completed by physician office staff. These included detailed information on age, race, gender, risk factors for acquisition of infection, clinical status, and confirmatory testing. Many patients appear to not have adequate follow-up for the management of this infection. Fax-back surveillance in the case of HCV is feasible and provides much-needed patient-level information.