True transition to practice: a role-reversal simulation.

Implication Statement: This article explores a direct-observation simulation swapping resident and consultant roles as a measure to assess competence during the final "transition to practice" phase of residency. As indicated by the Royal College, assessment of competency in this stage should include direct observation; however, this is challenging to implement, both from the perspective of a busy clinical environment, but also logistically, as a final-stage resident is still a learner in a consultant clinic. Our suggested approach allows for both real-world experience for the resident as well as direct observation and assessment by the consultant, thus providing the resident with targeted, actionable feedback, as well as ensuring the final-stage resident is competent for practice. Énoncé des implications de la recherche: Cet article explore une simulation utilisant l'observation directe et où les rôles de résident et de consultant sont inversés comme moyen d'évaluation des compétences durant l'étape finale de la résidence, la « transition vers la pratique ¼. Le Collège royal indique qu'à ce stade, l'observation directe doit faire partie de l'évaluation des compétences; or, cette modalité d'évaluation est difficile à mettre en œuvre dans un environnement clinique animé et un contexte logistique où le résident est encore un apprenant dans une clinique de consultants. L'approche que nous proposons permet à la fois au résident d'acquérir une situation réelle et au consultant de faire une observation directe pour l'évaluation, et d'offrir une rétroaction ciblée et utile, tout en s'assurant que le résident en fin de parcours a les compétences requises pour pratiquer.

Reimbursement of care does not equal the distribution of hospital resources: an explorative case study on a missing link among Dutch hospitals.

BACKGROUND: Affordability and accessibility of hospital care are under pressure. Research on hospital care financing focuses primarily on incentives in the financial system outside the hospital. It is notable that little is known about (incentives in) internal funding in hospitals. Therefore, our study focuses on the budget allocation in hospitals: the distribution model. Based on our hypothesis that the reimbursement and distribution models in hospitals might interact, we gain knowledge about-, and insight into, the interaction of different reimbursement and distribution models used in Dutch hospitals, and how they affect the financial output of hospital care. METHODS: An online survey with 22 questions was conducted among financial senior management as an expert group in 49 Dutch hospitals. RESULTS: Ultimately, 38 of 49 approached experts fully completed the survey, which amounts to 78% of the hospitals we approached and 60% of all Dutch hospitals. The results on the reimbursement model indicate price * volume with adjusted prices above a maximum cap as the most common dominant contract type. On the internal distribution model, 75-80% of the experts reported incremental budgeting as the dominant budgeting method. Results on the interaction between the reimbursement and the distribution model show that both general and specific changes in contract agreements are only partially incorporated in hospital budgets. In 28 out of 31 hospitals with self-employed medical specialists, a relation is reported between the reimbursement model and the contracts with the Medical Consultant Group(s) in which the medical specialists are united. CONCLUSIONS: Our results in Dutch setting indicate a limited interaction between the reimbursement model and the distribution model. This lack of congruence between both models might limit the desired effects of incentives in contractual agreements aimed at the financial output. This applies to different reimbursement and distribution models. Further research into the various interactions and incentives, as visualized in our conceptual framework, could result in evidence-based advice for achieving affordable and accessible hospital care.

Implicit Bias and Patient Care: Mitigating Bias, Preventing Harm.

Introduction: Simulation is a valuable and novel tool in the expanding approach to racism and bias education for medical practitioners. We present a simulation case focused on identifying and addressing the implicit bias of a consultant to teach bias mitigation skills and limit harm to patients and families. Methods: Learners were presented with a case of a classic toddler's fracture in an African American child. The learners interacted with an orthopedic resident who insisted on child welfare involvement, with nonspecific and increasingly biased concerns about the child/family. The learners were expected to identify that this case was not concerning for nonaccidental trauma and that the orthopedic resident was demonstrating bias. They were expected to communicate with both the resident and the parent effectively to defuse the situation and prevent harm from reaching the family. A debrief and an anonymous survey followed the case. Results: Seventy-five learners participated, including pediatric and emergency medicine residents, fellows, attendings, and medical students. After the case, the majority of learners expressed confidence that they could recognize racial bias in the care of a patient (90%), ensure patient care was not influenced by racial bias (88%), and utilize a tool to frame a concern about bias (79%). Discussion: Participants felt that this simulation was relevant and effective and overall left the experience feeling confident in their abilities to identify and manage racially biased patient care. This anti-racist simulation offers an important skill-building opportunity that has been well received by learners.

Knowledge, perceptions and behaviours of endoscopists towards the use of artificial intelligence-aided colonoscopy.

BACKGROUND: Recent developments in artificial intelligence (AI) systems have enabled advancements in endoscopy. Deep learning systems, using convolutional neural networks, have allowed for real-time AI-aided detection of polyps with higher sensitivity than the average endoscopist. However, not all endoscopists welcome the advent of AI systems. METHODS: We conducted a survey on the knowledge of AI, perceptions of AI in medicine, and behaviours regarding use of AI-aided colonoscopy, in a single centre 2 months after the implementation of Medtronic's GI Genius in colonoscopy. We obtained a response rate of 66.7% (16/24) amongst consultant-grade endoscopists. Fisher's exact test was used to calculate the significance of correlations. RESULTS: Knowledge of AI varied widely amongst endoscopists. Most endoscopists were optimistic about AI's capabilities in performing objective administrative and clinical tasks, but reserved about AI providing personalised, empathetic care. 68.8% (n = 11) of endoscopists agreed or strongly agreed that GI Genius should be used as an adjunct in colonoscopy. In analysing the 31.3% (n = 5) of endoscopists who disagreed or were ambivalent about its use, there was no significant correlation with their knowledge or perceptions of AI, but a significant number did not enjoy using the programme (p-value = 0.0128) and did not think it improved the quality of colonoscopy (p-value = 0.033). CONCLUSIONS: Acceptance of AI-aided colonoscopy systems is more related to the endoscopist's experience with using the programme, rather than general knowledge or perceptions towards AI. Uptake of such systems will rely greatly on how the device is delivered to the end user.

The development of clinical reasoning throughout the training and career of psychiatrists in Singapore.

Objectives: The current study sought to explain how different professional experiences led Singaporean psychiatrists to alter their clinical reasoning processes as their careers evolved from psychiatry residents to senior consultant psychiatrists. Methods: The current qualitative study interviewed 26 clinicians at various stages of their psychiatric career, spanning residents to senior psychiatrists.  The authors used a constructivist grounded theory approach to structure the collection and analysis of data. Analyses produced a dense theoretical explanation rooted in the experiences of participants. Results: Several differences emerged between the way psychiatry residents and senior psychiatrists explained their reasoning process and the experiences on which they based their preference. Residents preferred using deductive logic-driven frameworks that were diagnosis-centric, because of the pressures they experienced during their training and assessments. Senior psychiatrists emphasized a more holistic and problem-centric approach. Participants attributed the changes that occurred over time to practical experiences, such as their greater clinical responsibility and independence, and individual experiences, such as growing sensitivity to the clinical reasoning process or their growing propensity for professional reflectiveness. These changes manifest as an increase in repertoire and flexibility in deployment of different clinical reasoning strategies. Conclusions: It is important for trainees to be aware of the deductive and inductive modes of clinical reasoning during supervision and to be comfortable with shifting clinical focus from diagnoses to specific individual problems. Training programs should provide and plan adequate longitudinal clinical exposure to develop clinical reasoning abilities in a way that allows consequences of decisions to be explored. Continued faculty development to ease the diversification of clinical reasoning skills should be encouraged, as should reflectivity in the learners during clinical supervision.

Hiding in plain sight: Inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

The views expressed here are based on my professional experience as a consultant obstetrician, and previous role as clinical head of service for a small (<1800 births/year) obstetric unit in Perth metro. The obstetric unit in which I work has no 24/7 on-site staffed theatre capacity, no high dependency unit, and at night is staffed by a resident medical officer and junior obstetric registrar, with a consultant on-call within 30 min travel time. Based on my review of the literature on obstetric services nationally and various state guidelines (see Sources section), other Australian metro-located obstetric services appear to have similar challenges, but in this paper I focus on the health service models and patient safety systems that I am most familiar with (Perth metro) and ask why obstetric services in this, and by inference, other areas of the country which have similar high population density, would continue to have these staffing/service profiles.

Weekly Proactive Telephone Breastfeeding Standard Care by Lactation Consultants in the First Month Postpartum Prolongs Breastfeeding for Up to 6 Months.

Many mothers, especially those with co-morbidities, do not achieve exclusive breastfeeding (EBF) for the first 6 months, with the loss of multiple health benefits including enhanced infant nutrition. We wished to evaluate whether proactive lactation consultant telephone advice in the first month postpartum improved breastfeeding rates for up to 6 months. A prospective cohort observational study was performed. Mother groupings included the following: Control (CG, n = 379)-standard postnatal care; Exposure (EG, n = 386)-standard postnatal care delivered by lactation consultant telephone contact for the first 3 weeks postpartum and then follow-up calls at 1, 3 and 6 months postpartum to ascertain breastfeeding status. Sore nipples (24%) and fussy/unsettled behaviour (14-19%) were common EG concerns. EG EBF rates were higher at 1 month (65% vs. 53%; p < 0.001), 3 months (57% vs. 49%; p = 0.041) and 6 months (45 vs. 33%; p < 0.001). EG EBF rates across the 6 months were higher for infants admitted to the NNU (52.9% vs. 37.5%, p = 0.003), obese mothers (58.3% vs. 37.2%, p < 0.001), mothers with depression (60.8% vs. 43.4%, p = 0.036) and all birth modes. Proactive early lactation advice significantly prolongs EBF and consequently enhances infant nutrition overall, including for mothers at risk of early breastfeeding cessation.