Perils of the Hidden Curriculum: Emotional Labor and "Bad" Pediatric Proxies.

Today's medical training environment exposes medical trainees to many aspects of what has been called "the hidden curriculum." In this article, we examine the relationship between two aspects of the hidden curriculum, the performance of emotional labor and the characterization of patients and proxies as "bad," by analyzing clinical ethics discussions with resident trainees at an academic medical center. We argue that clinicians' characterization of certain patients and proxies as "bad," when they are not, can take an unnecessary toll on trainees' emotions. We conclude with a discussion of how training in ethics may help uncover and examine these aspects of the hidden curriculum.

Was This Readmission Preventable? Qualitative Study of Patient and Provider Perceptions of Readmissions.

OBJECTIVES: Readmissions are a costly, burdensome, and potentially preventable occurrence in the healthcare system. With the renewed national focus on the cost and quality of health care, readmissions have become a major target for improvement; however, in general, the viewpoints of patients and healthcare providers have not been considered in these discussions. We aimed to compare provider and patient perspectives on the preventability of hospital readmissions. We also aimed to compare the factors that patients and providers perceive as contributing to readmissions. METHODS: We conducted descriptive statistics of readmissions using provider chart reviews (N = 213) on all readmissions to the University of North Carolina hospitalist service during a 6-month span. We also performed a qualitative analysis of those provider chart reviews, in addition to interviews with those readmitted patients (n = 23). We compared the percentage of providers versus patients who believed the readmission was preventable, and we explored the factors to which each group attributed the readmission. RESULTS: Providers stated that 30% of the readmissions were preventable, compared with only 13% of patients. Key contributing factors differed between providers and patients. Providers cited medical problems in 45% of readmissions, pain (24%), follow-up problems (22%), substance abuse (20%), and nonadherence (17%). Patients believed nothing could have been done to prevent them in 35% of readmissions, but they also cited medical problems (35%), incomplete diagnosis or treatment (22%), medication issues (17%), and system concerns (13%) as contributing to readmissions. CONCLUSIONS: These data suggest that patients and providers view the issue of readmissions differently and highlight potential areas for improvement.

Getting hip to vitamin D: a hospitalist project for improving the assessment and treatment of vitamin D deficiency in elderly patients with hip fracture.

BACKGROUND: Vitamin D deficiency is common in elderly patients with hip fracture, and clinical practice guidelines recommend screening this population. Our hospitalist group cares for all patients admitted with hip fracture, yet lacked a standardized approach to screening for and treating vitamin D deficiency in this population. OBJECTIVES: To standardize and improve the assessment and treatment of vitamin D deficiency in elderly patients with hip fracture. DESIGN: Quality improvement implementation. SETTING: Tertiary academic hospital. PATIENTS: Adults age >50 years with hip fracture. INTERVENTIONS: We implemented a computerized hip fracture order set with preselected orders for 25-OH vitamin D level and initial supplementation with 1000 IU/day of vitamin D. We presented a review of the literature and performance data to our hospitalist group. MEASUREMENTS: Percentage of patients with acute hip fracture screened for vitamin D deficiency and percentage of deficient or insufficient patients discharged on recommended dose of vitamin D (50,000 IU/wk if level <20 ng/mL). RESULTS: The percentage of patients screened for vitamin D deficiency improved from 37.2% (n = 196) before implementation to 93.5% (n = 107) after (P < 0.001). The percentage of deficient or insufficient patients discharged on the recommended vitamin D dose improved from 40.9% to 68.0% (P = 0.008). The prevalence of vitamin D deficiency or insufficiency (25-OH vitamin D level <30 ng/mL) was 50.0%. CONCLUSIONS: Simple interventions, consisting of a change in computerized order set and presentation of evidence and data from group practice, led to significant improvement in the assessment and treatment of vitamin D deficiency in elderly patients with hip fracture.