Diagnostic Challenges and Treatment Approach to Seronegative Autoimmune Encephalitis.

Seronegative autoimmune encephalitis (AE) is a rare, immune-mediated inflammatory syndrome that presents with a wide spectrum of neuropsychiatric symptoms, such as cognitive impairment, seizures, psychosis, focal neurological defects, and altered consciousness. This disease process presents with no identifiable autoimmune antibodies, which leads to uncertain diagnosis, delayed treatment, and prolonged hospital admissions. Early diagnosis and prompt treatment of AE should not be delayed, as early recognition and treatment leads to improved outcomes and disease reversibility for these patients. In this study, we present a case report of a 77-year-old male who presented with acutely altered mental status. This patient underwent an extensive workup and demonstrated no signs of clinical improvement throughout a prolonged hospital admission. The diagnostic challenges and treatment obstacles encountered during our care of this patient are described in this case report, along with recommendations for early diagnosis and prompt treatment for patients with suspected seronegative AE.

A Curriculum for Enhancing Physician Teaching Skills: The Value of Physician-Educator Partnerships.

Developing as a physician requires an enormous amount of complex training, and quality of instruction greatly affects training outcomes. But while physicians are expected to teach trainees within the clinic, they often do not receive formal training in effective instructional practices. Providing faculty development programs is one way that institutions can help physicians develop teaching skills, but these programs often are developed without the input of educational specialists and not based in educational theory. In this methodology paper, we describe a 5-module curriculum that was developed in a cross-disciplinary collaboration between instructional designers and physician faculty. By merging educational and medical expertise and using adult learning theory with the Charlotte-Danielson educational framework, an essentials for clinical teaching educational endorsement program (ECTEEP) was created as a feature of the institutional curriculum within a large, urban teaching hospital. Here we describe how the program was developed through a physician-educator partnership, outline the program's key content, and highlight essential aspects of successful implementation. The ECTEEP incorporates active learning approaches within an abbreviated format, distilling 5 critical aspects of effective teaching that are relevant to the clinical environment: cultural humility and safe learning environments, instruction practices for engaging learners, instruction and assessment strategies, receiving and giving feedback, and mentorship and coaching. A central feature of the program is that facilitators actively model the teaching behaviors they are conveying, which underscores the critical importance of facilitator preparation and skill. Our curriculum is offered here as a basic template for institutions that may want to establish a program for enhancing physician teaching skill.

Visual Analytics Dashboard Promises to Improve Hypertension Guideline Implementation.

BACKGROUND: Primary care management of hypertension under new guidelines incorporates assessment of cardiovascular disease risk and commonly requires review of electronic health record (EHR) data. Visual analytics can streamline the review of complex data and may lessen the burden clinicians face using the EHR. This study sought to assess the utility of a visual analytics dashboard in addition to EHR in managing hypertension in a primary care setting. METHODS: Primary care physicians within an urban, academic internal medicine clinic were tasked with performing 2 simulated patient encounters for hypertension management: the first using standard EHR, and the second using EHR paired with a visual dashboard. The dashboard included graphical blood pressure trends with guideline-directed targets, calculated atherosclerotic cardiovascular disease risk score, and relevant medications. Guideline-appropriate antihypertensive prescribing, correct target blood pressure goal, and total encounter time were assessed. RESULTS: We evaluated 70 case simulations. Use of the dashboard with the EHR compared with use of the EHR alone was associated with greater adherence to prescribing guidelines (95% vs. 62%, P < 0.001) and more correct identification of blood pressure target (95% vs. 57%, P < 0.01). Total encounter time fell an average of 121 seconds (95% confidence interval 69-157 seconds, P < 0.001) in encounters that used the dashboard combined with the EHR. CONCLUSIONS: The integration of a hypertension-specific visual analytics dashboard with EHR demonstrates the potential to reduce time and improve hypertension guideline implementation. Further widespread testing in clinical practice is warranted.

Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic.

BACKGROUND: Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016. OBJECTIVE: To improve our clinic's CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions. DESIGN: A quality improvement project led by a multidisciplinary group of healthcare providers. PARTICIPANTS: Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population. INTERVENTION: Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period. MAIN MEASURES: Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population's CCS rate for all eligible clinic patients. KEY RESULTS: After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P < 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P < 0.001). Our clinic's CCS rate improved from 70% to 75% after the 18-month intervention. CONCLUSIONS: The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS.