The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial.

Importance: Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. Objective: To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections. Design, Setting, and Participants: This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. Interventions: Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. Main Outcomes and Measures: Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). Results: Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004). Conclusions and Relevance: Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections. Trial Registration: ClinicalTrials.gov Identifier: NCT03638947.

A five-year retrospective evaluation of a faculty research fellowship programme at the medical college of Georgia.

INTRODUCTION: In institutional assessments of faculty, scholarly activity is often cited as a deficiency. Faculty lack the training and resources needed to produce peer-reviewed, quality scholarship. Although a variety of formats have been suggested and used to fill this void, fellowships are a commonly used format to foster educational leaders within institutions. In 2010, the Educational Innovation Institute at the Medical College of Georgia created an educational research fellowship to address this need. METHODS: To assess the success of our programme, we compared all graduating fellows' current curriculum vitae (CVs) with the version submitted at the time of their application, looking for educational scholarship produced during and after their participation in the fellowship. Qualitative data sources, such as article reflections, mid-fellowship surveys, and exit surveys were analyzed to identify the mechanisms that contributed to their success. The constant comparative method was used to identify themes and patterns. RESULTS: A comparison of CVs collected at the time of application with a current CV indicate the 11 participants produced: 60 presentations at regional or national meetings, 16 peer reviewed publications, received funding for 7 grants supporting educational research, and won 7 national research awards. Our qualitative analysis identified three major mechanisms: 1) dedicated time to conducting educational research, 2) opportunities to engage with others, and 3 ) understanding the differences between educational and clinical research. DISCUSSION: Previous criticisms of fellowships include faculty not producing educational scholarship after completing their programme. Our retrospective analysis indicates our research fellowship was successful in developing physicians and clinical educators to become educational researchers. What was most useful was having dedicated time to work with others interested in producing educational scholarship, and expert guidance in understanding the differences between clinical and educational research. The most challenging aspect of conducting education research was their need to use conceptual frameworks and learning theory in their work. Implications for this study include the need for a strong curricular focus on the differences between clinical and educational research for any fellowship programme.

Utilising Medicare annual wellness visits to implement interprofessional education in the primary care setting.

Interprofessional education (IPE) is an important component of healthcare professional curriculum in order to optimally prepare students for their roles as part of the healthcare team. Integrating IPE activities into direct patient care in the primary care clinic setting can help improve perceptions and student understanding of other healthcare professionals' responsibilities in this ever-evolving practice setting. This report describes the implementation of an interprofessional clinic including a variety of healthcare professionals and students in the context of the Medicare Annual Wellness Visits (AWV). Design of the clinic and general roles of the professionals in optimising preventive care are described. Student perceptions of IPE and their knowledge of other healthcare professionals were also surveyed. Student knowledge of other professionals mildly improved. Student perception of actual cooperation and interprofessional interaction statistically improved, while perception of interprofessional learning slightly worsened. Utilising Medicare AWVs can be a way for various professionals to improve IPE in the primary care setting.

Epistemology and uncertainty: a follow-up study with third-year medical students.

BACKGROUND AND OBJECTIVES: Prior research results indicate a relationship between medical epistemology (ie, how a physician organizes and prioritizes the biological and psychosocial data of a patient presentation) and stress reactions to uncertainty among primary care physicians. However, little is known about when this relationship forms. The purpose of this study was to begin answering this question by exploring the relationship between medical epistemology and stress reactions to uncertainty among a group of 89 third-year medical students from the class of 2010 of a three-campus state medical school located in the southwestern US. METHODS: Data from Likert-type measures of medical epistemology and stress reactions to uncertainty were extracted from course evaluation information that was collected at the start (T1) and end (T2) of a continuity clinic experience that spanned most of the students' third year. Using these data, the authors conducted a simple bivariate regression analysis to identify the relationship between medical epistemology and stress reactions to uncertainty (Model 1), and a multivariate regression analysis to test for the independent effect of medical epistemology on stress reactions to uncertainty while controlling for gender and specialty interest (Model 2). These two regression models were calculated for both the T1 and T2 data sets. RESULTS: The two regression models at T1 indicated no significant relationships between medical epistemology and stress reactions to uncertainty; however, the two regression models at T2 indicated that a biopsychosocial epistemology is associated with less stress reactions to uncertainty, and a biomedical epistemology is associated with more stress reactions to uncertainty. CONCLUSIONS: The third year is an opportune time for medical educators to help shape and develop students' medical epistemology and stress reactions to uncertainty.

An evaluation of family medicine residents' attitudes before and after a PCMH innovation for patients with chronic pain.

BACKGROUND AND OBJECTIVES: Prior research indicates that primary care physicians have predominantly negative attitudes toward chronic pain patients, and chronic pain patients have predominantly low satisfaction with the care and treatment they receive in primary care. This current state of affairs highlights the need for Patient-centered Medical Home (PCMH) innovations for the treatment of chronic pain in primary care. The purpose of this study was to determine if a PCMH innovation for the treatment of chronic pain in a family medicine residency program can improve resident attitudes toward chronic pain patients. METHODS: From January 2010 to December 2010, 30 family medicine residents (two--three per month) participated in twice-a-month PCMH innovation for the treatment of chronic pain in primary care ("pain clinic"). De-identified data from a Likert-type measure of negative attitudes toward chronic pain patients were extracted from pain clinic evaluation information that was collected shortly before (pretest) and shortly after (posttest) the residents' pain clinic participation. Using these data, we conducted a paired-samples t test to determine if residents' negative attitudes toward chronic pain patients had improved. RESULTS: The difference between residents' pretest scores (M=51.2, SD=10.9) and posttest scores (M=45.2, SD=9.2) was significant, suggesting that residents' negative attitudes toward chronic pain patients improved after participating in pain clinic. CONCLUSIONS: A PCMH innovation for the treatment of chronic pain in primary care can improve family medicine residents' attitudes toward chronic pain patients.

Epistemology and uncertainty in primary care: an exploratory study.

BACKGROUND AND OBJECTIVES: Primary care is an endeavor marked by breadth, complexity, and more clinical uncertainty than all non-primary care specialties except psychiatry. This is significant, as uncertainty is associated with a variety of troublesome economic and clinical indicators. Researchers have identified the three types of cognitive resources needed to combat uncertainty (technical, personal, or conceptual), as well as the affective stress reactions physicians have when confronted with uncertainty. In this study, we explored the relationship between primary care physicians' stress reactions to uncertainty and the conceptual resource of epistemology. METHODS: Using Likert-type measures of epistemology and stress reactions to uncertainty, we conducted a cross-sectional survey with 78 board-certified and resident physicians in primary care. A simple bivariate regression analysis was performed to identify the relationship between epistemology and stress reactions to uncertainty (Model 1), and a multivariate regression analysis was performed to test for the independent effect of epistemology on stress reactions to uncertainty while controlling for gender, specialty, and professional development status (Model 2). RESULTS: Physician epistemology and stress reactions to uncertainty were significantly related in both models. CONCLUSIONS: Among primary care physicians, a biopsychosocial epistemology is associated with less stress reactions to uncertainty, and a biomedical epistemology is associated with more stress reactions to uncertainty.