Feedback conversations: First things first?

OBJECTIVE: This study explores medical students' perceptions regarding the order in which feedback is given and its impact on how that feedback is received. METHODS: Medical students were interviewed regarding their feedback experiences during medical school and preferred order in which to receive feedback. Thematic analysis was applied to interview transcripts to identify salient themes in students' comments related to feedback order. RESULTS: Twenty-five students entering their second, third, and fourth years of medical school participated in the study. Students indicated that the order in which feedback was conveyed influenced their receptivity to its content, but varied in their specific order preferences. Most students indicated that they preferred feedback conversations that started with positive observations. Only the most senior students expressed a preference for feedback based on self-assessment. CONCLUSION: Feedback conversations are complicated interactions. Students' responses to feedback are influenced by a variety of factors, including the order in which feedback is delivered. PRACTICE IMPLICATIONS: Educators should recognize that students' feedback needs may be influenced by a variety of factors, and should aim to tailor feedback and the order of its delivery to the learner.

Self-Assessment in Feedback Conversations: A Complicated Balance.

PURPOSE: Learner-centered feedback models encourage educators to ask learners to self-assess at the start of feedback conversations. This study examines how learners perceive and respond to self-assessment prompts during feedback conversations and assesses medical students' perceptions of and approach to self-assessment used as the basis for these conversations. METHOD: All rising second-, third-, and fourth-year medical students at a midwestern U.S. medical school were invited to participate in this study. Students participated in 1-on-1 interviews between June and August 2019 during which they were asked open-ended questions about their experiences with self-assessment and feedback during medical school. The interviews were audio recorded and transcribed, and comments related to self-assessment in feedback conversations were extracted. Thematic analysis was used to identify recurrent ideas and patterns within the transcripts, and all excerpts were reviewed and coded to ensure that the identified themes adequately captured the range of student responses. RESULTS: A total of 25 students participated in the study. Although some students noted improvement in their self-assessment abilities with increasing experience, no consistent gender, race, or training-level differences were found in reported attitudes or preferences. Students identified many benefits of self-assessment and generally appreciated being asked to self-assess before receiving feedback. Students had varied responses to specific self-assessment prompts, with no clear preferences for any particular self-assessment questions. Students described weighing multiple factors, such as image concerns and worries about impact on subsequent evaluations, when deciding how to respond to self-assessment prompts. CONCLUSIONS: The process by which learners formulate and share self-assessments in feedback conversations is not straightforward. Although educators should continue to elicit self-assessments in feedback discussions, they should recognize the limitations of these self-assessments and strive to create a safe environment in which learners feel empowered to share their true impressions.

Creation and maintenance of a table for assessment of evolving evidence for COVID-19-related treatments.

PURPOSE: This report describes the development and maintenance of a table to present an assessment of evidence for treatments used in patients with coronavirus disease 2019 (COVID-19). SUMMARY: AHFS Drug Information (AHFS DI) (American Society of Health-System Pharmacists, Bethesda, MD) is ASHP's evidence-based drug compendium that contains drug monographs written for pharmacists and other healthcare professionals. The professional editorial and analytical staff of pharmacists critically evaluate published evidence to develop drug monographs for AHFS DI. In response to the global COVID-19 pandemic, these skills were applied to assess emerging evidence for COVID-19-related treatments, and the information was compiled into a new resource for pharmacists and other healthcare professionals to use at the point of care. A list of therapies was developed and prioritized based on review of scientific and public discussions on the use of these therapies in patients with COVID-19; certain therapies used for supportive care and therapies that might theoretically be harmful to patients with COVID-19 also were considered for inclusion. Potential treatments were identified, and the evidence for use in patients with COVID-19 was assessed and summarized in a table format. Information presented for each therapy included the rationale for use, summaries of clinical trials or experience, trial registry numbers, and dosage regimens. Comments on safety and efficacy, including limitations of available data, were presented along with recommendations from recognized authorities. The editorial team continued to add new therapies to the table and update existing entries as new evidence emerged. CONCLUSION: A comprehensive table that summarized available evidence for potential treatments for patients with COVID-19 was developed. The table format enabled the drug information editorial staff to provide ongoing updates as new information emerged during the pandemic.

Working With Interpreters as a Team in Health Care (WITH Care) Curriculum Tool Kit for Oral Health Professions.

Introduction: Limited English proficiency (LEP) patients face multiple care barriers and disproportionate risks for communication errors. Working with trained interpreters as a health care team can improve communication and drive high-quality care for LEP patients. Simulation and interprofessional education provide key strategies to address the critical training gap that exists at the intersection of patient safety, interprofessional practice, and cultural competence. Methods: Using action research principles across 16 months, we created a 3.5-hour simulation-based training for oral health and interpreting learners. The curriculum included profession-specific orientations with didactic and experiential content, three immersive simulations using start-stop-rewind methodology, virtual scenarios, and summary reflection discussions. A comprehensive tool kit facilitated curriculum implementation and standardization. Results: Forty-nine students from dentistry (first- through third-year predoctoral), dental hygiene, and dental therapy participated in this elective training during the 2017-2018 academic year; as required training, 126 third-year dental students participated in fall 2018. Students' familiarity with provider and interpreter best practices, appreciation of challenges faced by LEP patients, and confidence in skills working with spoken language interpreters increased. For all evaluation parameters, pre- and postsurvey ratings were statistically significant (chi-square tests, p < .001). Discussion: The curriculum efficiently and effectively develops oral health and interpreting learners' abilities to work as a team with LEP patients. Curriculum design and resources address key barriers to feasibility and sustainability. The curriculum informs communication across all patient populations, revealing that getting by with partial understanding can be insufficient for any patient and any health care team.

Creating and Evaluating Skills-Based Training in Working with Spoken-Language Interpreters for Oral Health Professions Students.

In a multicultural society, the ability to work effectively with spoken-language interpreters is a critical skill for oral health professionals. The aims of this study were to design and evaluate training for oral health professions students to work effectively with interpreters as a health care team. A total of 89 University of Minnesota dental, dental hygiene, and dental therapy students and 41 Century College translating and interpreting students participated in the elective three-hour training from 2016 to 2018. The 89 oral health professions participants were invited to respond to a seven-item survey about working with interpreters and patients who are limited English proficient (LEP), along with a comparison group of an additional 462 oral health professions students who did not participate in the program. Of the oral health professions participants, 49 responded to the survey, for a 55% response rate; and 245 of the comparison group responded, for a 53% response rate. A qualitative focus group with 11 program participants and inductive analysis provided further insights. The differences between participants' pre and post self-ratings were statistically significant (p<0.001) for each of the seven survey questions. After training, students were more familiar with provider and interpreter best practices and the context for patients who are LEP, as well as more confident in their skills to work effectively with interpreters. Student focus groups identified training relevance and necessity and learning format as the most significant success factors. This project highlights the process and value of creating these experiences for and with students and the value of simulation to develop knowledge, skills, and confidence.

Physical Examination for Men and Women With Urologic Chronic Pelvic Pain Syndrome: A MAPP (Multidisciplinary Approach to the Study of Chronic Pelvic Pain) Network Study.

OBJECTIVE: To examine the feasibility of implementing a standardized, clinically relevant genitourinary examination for both men and women, and to identify physical examination findings characteristic of urologic chronic pelvic pain syndrome (UCPPS). MATERIALS AND METHODS: This study analyzed 2 samples: men and women with UCPPS who participated in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network Epidemiology and Phenotyping (EP) Study, and age-matched controls who were either positive for chronic fatigue syndrome or healthy (pain-free). We compared physical examination findings in both positive and healthy controls with UCPPS cases: findings from both the EP examinations and from an extended genitourinary examination. RESULTS: EP and extended examinations were performed on 143 participants: 62 UCPPS cases (30 women, 32 men), 42 positive controls (15 women, 27 men), and 39 healthy controls (22 women, 17 men). EP examinations showed that pelvic floor tenderness was more prevalent in cases (55.0%) than in positive (14.6%) or healthy controls (10.5%). Extended examinations revealed specific areas of tenderness in the pelvic floor musculature. Cases were also more likely than healthy controls to report tenderness in multiple areas, including suprapubic, symphysis pubis, and posterior superior iliac spine, and on bimanual examination. No comparative findings were specific to biological sex, and no evidence of pudendal neuropathy was observed on extended examination of cases or controls. CONCLUSION: The extended genitourinary examination is an easily administered addition to the assessment of men and women during evaluation for UCPPS. Physical findings may help to better categorize patients with UCPPS into clinically relevant subgroups for optimal treatment.

Successful pregnancy in patients with exstrophy-epispadias complex: A University of Washington experience.

INTRODUCTION: With advances in genitourinary reconstructive surgery, women with exstrophy-epispadias complex (EEC) have improved health and quality of life, and may reach reproductive age and consider pregnancy. Despite literature suggesting impaired fertility and higher risk with pregnancy, childbirth is possible. Medical comorbidities, including müllerian anomalies, contribute to increased risk of obstetric and urologic complications during pregnancy. OBJECTIVES: We reviewed our experience with EEC patients who achieved pregnancy to investigate (1) urological characteristics of women who achieved pregnancy; (2) pregnancy management, complications, and delivery; and (3) neonatal outcomes. We developed recommendations for managing pregnancy in women with EEC. STUDY DESIGN/RESULTS: This was a retrospective chart review of 36 female patients with EEC seen at our institution between 1996 and 2013. Female patients less than 18 years, and patients who did not have documented pregnancy were excluded. This resulted in a total of 12 patients with 22 pregnancies. All women with successful pregnancy had bladder exstrophy. The majority had undergone prior bladder augmentation (75%) and were on self-catheterization programs (92%). Thirty-six percent had symptomatic urinary tract infections (UTIs) during pregnancy. Five women had more than one pregnancy. There were four terminations of pregnancy. Of 18 desired pregnancies, there were four spontaneous abortions (SABs) (22%) and 16 live births (78%). The cesarean delivery (CD) rate was 100% (14/14), of which the majority were vertical (classical) uterine incisions with a paramedian skin incision. With the exception of one patient, there were no CD surgical complications. The mean gestational age at delivery was 36 weeks (Range 25 4/7 to 39 4/7 weeks) among eight pregnancies with known gestational age. There were no stillbirths, one neonatal death and no birth defects. DISCUSSION: Women with EEC can have successful pregnancies, though at increased risk for preterm delivery and SABs. In our cohort, the rate of SAB is similar to that described in prior studies. Symptomatic UTIs likely due to self-catheterization were common. Cesarean delivery using a paramedian skin incision and classical uterine incision were not associated with major complications in this cohort. Limitations include reliance on retrospective data and small sample size. The strength of this study is the longitudinal detailed management of pregnancies in EEC women by a single team over time. A multidisciplinary approach to providing a continuum of care from pediatrics through adolescence to adulthood optimizes successful transitions, reproductive health, and successful pregnancies. Based on our experience, an algorithm providing guidance for pregnancy management was developed.

Reoperation after sacral neuromodulation therapy: a single-institution experience.

OBJECTIVES: Sacral neuromodulation has become an accepted treatment for various types of lower urinary tract dysfunction. However, despite technologic advances in device implantation and a trial stimulation period, sacral neuromodulation still has a significant reoperation rate. We report our single-institution experience of reoperation rates. METHODS: We performed a retrospective review of our patients who had undergone the implantation of the InterStim device from April 1999 to December 2011 for lower urinary tract dysfunction. RESULTS: A total of 155 InterStim devices were implanted by 2 surgeons. Of the 142 patients with complete follow-up, 55 (38.2%) patients required reoperation, for either revision or explantation of the device. Revisions were performed in 30 (21.1%) patients, most commonly for mechanical failure of device, battery end-of-service, and pain, either at the site of the implanted pulse generator or with stimulation. Of the 30 patients who underwent revision, 14 had successful results, 6 had persistent symptoms, and 10 progressed to eventual explantation.The overall explantation rate was 24.6% (35 of 142 patients), and the average time to removal was 44 months. Most of the explantations were performed for poor symptom control and failure to maintain response (74.3%).Reoperation was not associated with age, sex, obesity, diabetes, chronic pain, use of the tined lead, or type of lower urinary tract dysfunction. CONCLUSIONS: Sacral neuromodulation has a substantial revision and explantation rate, without any clear predictors for these complications. Patients should be counseled to these complications before surgery.

A pilot study of botulinum toxin for interstitial cystitis/painful bladder syndrome.

OBJECTIVES: Preliminary studies using botulinum toxin (BTX) have demonstrated some benefits in treating interstitial cystitis (IC)/painful bladder syndrome (PBS) pain. The purpose of this study was to investigate the efficacy of a periurethral injection of BTX to block urethral visceral and somatic afferent fibers, for the treatment of IC/PBS. METHODS: Twenty adult women with IC/PBS were identified from the Female Urology Clinic at our hospital. Symptom evaluation was performed using a female modification of the Chronic Prostatitis Symptom Index (CPSI), AUA Symptom Index, Graded Chronic Pain Scale, Perceived Stress Scale, and symptom improvement Visual Analog Scale (VAS). All patients were randomized to receive either botulinum toxin A (BTX-A) or placebo (normal saline). Patients randomized to BTX-A received 50 U diluted in 2 cm(3) normal saline injected periurethrally. The physician and patient were blinded to the treatment. RESULTS: BTX was administered to nine women. There were no complications or side effects reported. There was no improvement between placebo and BTX-A groups in the CPSI score at 3-month follow-up (P=0.97). Additionally, there were no improvements in the other symptom indices. At follow-up, the mean VAS for the BTX group was -0.3, indicating the subjects' symptoms were the same as at the start of the study. CONCLUSIONS: Periurethral injection of botulinum toxin in women did not effectively treat the pain of IC/PBS. While the results from this study are negative, there is still a valid rationale for further investigations of novel injection protocols given the dearth of current effective treatments.

Bladder neck closure and suprapubic tube placement in a debilitated patient population.

AIMS: Bladder neck closure (BNC) with suprapubic tube (SPT) placement is a method of bladder management for patients with neurogenic bladders (NGB). We evaluated our experience at one institution. METHODS: We conducted a retrospective chart review of patients who received BNC with SPT placement from 1999 to 2008. RESULTS: Twenty-nine patients (24 females and 5 males, average age 53.4 +/- 9.6 years) underwent BNC with SPT placement. Cause of NGB was multiple sclerosis (48%), spinal injury (28%), or myelodysplasia (17%). All but one were dependent on caregivers for activities of daily living. Preoperative urodynamics studies were performed on 23 patients. Retropubic BNC was performed in 26 of 29 patients. Two females had a transvaginal approach, and one male had a perineal approach. Early (<90 days) postoperative complication rate was 52%. Persistent urine leakage was present in eight patients: two peristomal leakage and six urethral leakage. All three non-retropubic BNC had postoperative fistulas (P = 0.01). Catheter complications were associated with seven of the eight urinary leaks (P = 0.01). CONCLUSIONS: BNC with SPT is a method of bladder management in the NGB population, particularly suited to those with a low functional status. Fistula rates are significantly higher with non-retropubic BNC (P = 0.01). Poor catheter care in the postoperative period is associated with postoperative urinary leakage (P = 0.01).

Complications from transvaginal pubovaginal slings using bone anchor fixation.

OBJECTIVES: To evaluate the history and management of complications from transvaginally placed pubovaginal slings using bone anchor fixation. METHODS: During a 3-year period, 10 patients were referred to us for complications related to transvaginally placed pubovaginal slings using bone anchor fixation. RESULTS: The patient age ranged from 42 to 73 years. All women had a vaginally introduced bone anchor sling for stress urinary incontinence. The presenting symptoms after surgery included fever, pain, and difficulty ambulating in 1; pain and/or vaginal dyspareunia with discharge in 5; pain or dyspareunia alone in 2; and vaginal discharge alone in 2 patients. Two patients ultimately developed bone lesions on radiologic studies consistent with osteomyelitis. Six patients developed sinus drainage tracts associated with granulation tissue from at least one bone anchor that was unresponsive to outpatient management. One of the patients with pain alone had a permanent suture extending into the bladder neck. Nine patients underwent surgery, of whom five had resolution of their presenting complaint. Four of these patients were continent at last follow-up. CONCLUSIONS: Transvaginally placed pubovaginal slings using bone anchors can be associated with serious complications that may be intractable to common therapies. This knowledge may enable practitioners who use this technique to better counsel their patients regarding these significant complications.

Relationship between patient report and physician assessment of urinary incontinence severity.

OBJECTIVE: The purpose of this study was to determine the relationship between patient report and physician assessment of urinary incontinence severity and to compare these assessments to a validated severity instrument. STUDY DESIGN: A sequential sample of 153 women with urinary incontinence was enrolled over 12 months. Patients completed a detailed health questionnaire that included a medical comorbidity scale, 12-item short-form health survey (SF-12) the incontinence quality of life instrument, the PRIME-MD patient health questionnaire, and a patient incontinence severity assessment. The patient incontinence severity assessment is a single question that asks the patient to rate the severity of her incontinence symptoms on a 5-point Likert scale (range: 1 [mild] to 5 [severe]). After the physicians completed a detailed history, a physical examination, and a review of a 3-day voiding diary, they assigned a physician incontinence severity assessment score. The physician incontinence severity assessment is a physician rating of the severity of the patient's incontinence on a 5-point Likert scale (range: 1 [mild] to 5 [severe]). A validated severity index was computed and used for comparison. This is a multiplicative index that is based on frequency (4 levels) and amount of leakage (2 levels), which yields an index value of 1 to 8. Spearman correlation coefficients were calculated for patient incontinence severity assessment, the physician incontinence severity assessment scores, and the severity index values. Chi-square tests were used to determine differences between patient incontinence severity assessment and physician incontinence severity assessment ratings. RESULTS: Spearman correlation coefficients for patient incontinence severity assessment and physician incontinence severity assessment were 0.62 (P <.001), for patient incontinence severity assessment and the severity index was 0.61 (P <.001), and for physician incontinence severity assessment and the severity index was 0.66 (P <.001). Agreement between patient assessment and physician assessment for different severity levels on the patient incontinence severity assessment and physician incontinence severity assessment are provided. CONCLUSION: There is a high correlation between patient report and physician assessment of urinary incontinence severity. Both patient reports (patient incontinence severity assessment) and physician assessments (physician incontinence severity assessment) correlate well with a validated severity index. The agreement between patient and physician ratings is very high for mild incontinence but decreases as incontinence severity progresses.

Urinary tract infections cranberry juice, underwear, and probiotics in the 21st century.

There is a substantial gap between the viewpoint of urologists and the rest of society regarding UTIs. Urologists spend little time and effort thinking about UTIs. In contrast, UTIs are a major issue for many women. There is substantial concern about "natural compounds" and probiotics that allow women to take charge of their health care. It is easy to understand this concern because UTIs are common, costly, and cause considerable morbidity.

Hormonal manipulation in women with chronic, cyclic irritable bladder symptoms and pelvic pain.

OBJECTIVE: Chronic, painful bladder symptoms are diagnostic and therapeutic challenges for urologists and gynecologists. The aims of this study were to evaluate women with menstrual cycle-related changes in their interstitial cystitis symptoms, to treat them with hormonal manipulation, and to follow them long term. STUDY DESIGN: The cases of women who were referred to a tertiary care center with interstitial cystitis and menstrual cycle exacerbation of symptoms were evaluated in a retrospective study. Fifteen women had undergone laparoscopy that was followed immediately by cystoscopy and bladder hydrodistension. Patients were then treated with leuprolide acetate or oral contraceptive pills. RESULTS: Patient age ranged from 23 to 48 years. The duration of symptoms ranged from 1 to 26 years. Ten patients (67%) had findings of both interstitial cystitis and peritoneal endometriosis. Five of 15 patients (33%) had interstitial cystitis, but no endometriosis was found. Symptoms improved for 8 of 9 women who were treated with leuprolide acetate and for 5 of 6 women who were treated with oral contraceptive pills. Patients were followed up for an average of 55 months. CONCLUSION: Diagnostic laparoscopy should be considered together with hydrodistension of the bladder for women with pelvic pain and irritative bladder symptoms that are exacerbated premenstrually. Endometriosis is often present in patients with these complex symptoms. This is the first report of hormonal treatment for chronic, cyclic irritative bladder symptoms; improvement appears to occur even when endometriosis is not identified by laparoscopy.