"Where You Feel Like a Family Instead of Co-workers": a Mixed Methods Study on Care Teams and Burnout.

BACKGROUND: Physicians and nurses face high levels of burnout. The role of care teams may be protective against burnout and provide a potential target for future interventions. OBJECTIVE: To explore levels of burnout among physicians and nurses and differences in burnout between physicians and nurses, to understand physician and nurse perspectives of their healthcare teams, and to explore the association of the role of care teams and burnout. DESIGN: A mixed methods study in two school of medicine affiliated teaching hospitals in an urban medical center in Baltimore, Maryland. PARTICIPANTS: Participants included 724 physicians and 971 nurses providing direct clinical care to patients. MAIN MEASURES AND APPROACH: Measures included survey participant characteristics, a single-item burnout measure, and survey questions on care teams and provision of clinical care. Thematic analysis was used to analyze qualitative survey responses from physicians and nurses. KEY RESULTS: Forty-three percent of physicians and nurses screened positive for burnout. Physicians reported more isolation at work than nurses (p<0.001), and nurses reported their care teams worked efficiently together more than physicians did (p<0.001). Team efficiency was associated with decreased likelihood of burnout (p<0.01), and isolation at work was associated with increased likelihood of burnout (p<0.001). Free-text responses revealed themes related to care teams, including emphasis on team functioning, team membership, and care coordination and follow-up. Respondents provided recommendations about optimizing care teams including creating consistent care teams, expanding interdisciplinary team members, and increasing clinical support staffing. CONCLUSIONS: More team efficiency and less isolation at work were associated with decreased likelihood of burnout. Free-text responses emphasized viewpoints on care teams, suggesting that better understanding care teams may provide insight into physician and nurse burnout.

High Value Care in Cancer Surveillance and Screening: Evaluating an e-Curriculum for Primary Care Providers.

BACKGROUND: With an expected shortage of oncologists, primary care providers (PCPs) may need to manage more cancer surveillance and screening, areas where educational resources for PCPs have been limited. The goal of this e-curriculum was for PCPs to learn surveillance and screening for several common cancers. METHODS: The e-curriculum covered breast and colorectal cancer surveillance and lung cancer screening with (1) a pre-test assessing knowledge, attitudes, practice patterns, and confidence; (2) case vignette-based teaching; and (3) an immediate post-test (with knowledge and confidence items identical to the pre-test) providing feedback. A delayed post-test was administered several months later. The curriculum and test items were developed by content experts and evaluated in a primary care group practice. RESULTS: Of 167 community PCPs, 152 completed the pre-test (91%), 145 completed the immediate post-test (87%), and 63 completed the delayed post-test (37%); 62 PCPs completed all three tests (37%). The median score on the pre-test was 43%, immediate post-test was 93%, and delayed post-test was 70%. For PCPs completing all three tests, the median scores were 50%, 90%, and 70%, respectively (p < 0.0001). The percentage of PCPs confident in their knowledge 4 to 6 months after module completion compared to the pre-test baseline was statistically significant for lung cancer screening but not for cancer surveillance. CONCLUSION: This curriculum provided concise, effective education for PCPs on 3 common cancers. Limitations include content breadth and lack of data reflecting physician ordering patterns. Curricular strengths include its accessibility, immediate feedback, and effectiveness, with a significant improvement in immediate and delayed post-test knowledge. Given a lack of increased confidence to provide cancer surveillance, PCPs should rely on electronic medical record tools and other resources to guide appropriate surveillance care.

Team-Based Health Information Exchange Use Increased Mammography Documentation and Referral in an Academic Primary Care Practice: An Interrupted Time Series.

BACKGROUND: Few studies have examined the impact of health information exchanges (HIE) on quality in ambulatory settings. METHODS: From September 29, 2014, to September 4, 2015, we conducted an interrupted time series analysis of query-based use of the state HIE as part of team-based care to improve mammography screening in an academic primary care practice. Women aged 50-74 years with a practice visit and who were eligible for mammography were included. We conducted non-parametric data analysis using LOESS, followed by ARIMA analysis. RESULTS: During the study period, there were 2020 visits among 904 eligible patients, including 648 visits among 485 patients during 16 baseline weeks, and 1372 visits by 755 patients during 33 intervention weeks. During the intervention period, 16.0% of eligible women who were not up to date in our EHR had a mammogram in the HIE. Of eligible women, the proportion who had a documented up-to-date mammogram at the time of their visit increased by 11.3%, from 73.4% at baseline to 84.7% (p < 0.0001), the proportion who had mammography addressed at the time of their visit increased by 42.7%, from 32.7% at baseline to 75.4% (p < 0.0001), and the proportion who were up to date at 8 weeks post-visit increased by 11.7%, from 76.3% at baseline to 88.0% (p < 0.0001). DISCUSSION: Query-based use of the state HIE as part of team-based care improved documentation of mammography and led to an increase in the proportion of eligible women who received counseling on mammography screening in one primary care practice. These results suggest that HIE use in primary care could lead to improved delivery of other preventive services.

Implementing the Comprehensive Unit-Based Safety Program (CUSP) to Improve Patient Safety in an Academic Primary Care Practice.

BACKGROUND: While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. METHODS: As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire. RESULTS: Ninety-six percent of staff completed science of safety training as part of CUSP implementation, and 100% of staff completed the two-question safety assessment. The most frequently identified safety concerns were related to medications (n = 11, 28.2), diagnostic testing (n = 9, 25), and communication (n = 5, 14). The CUSP team initially prioritized communication and infection control, which led to standardization of work flows within the practice. Six months following CUSP implementation, large but nonstatistically significant increases were found for the percentage of survey respondents who reported knowledge of the proper channels for questions about patient safety, felt encouraged to report safety concerns, and believed that the work setting made it easy to learn from the errors of others. CONCLUSION: CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care.

The genealogy of teaching clinical reasoning and diagnostic skill: the GEL Study.

The genealogy of graduate medical education in America begins at the bedside. However, today's graduate medical trainees work in a training environment that is vastly different from medical training a century ago. The goal of the Graduate Medical Education Laboratory (GEL) Study, supported by the American Medical Association's (AMA) "Reimagining Residency" initiative, is to determine the factors in the training environment that most contribute to resident well-being and developing diagnostic skills. We believe that increasing time at the bedside will improve clinical skill, increase professional fulfillment, and reduce workplace burnout. Our graduate medical education laboratory will test these ideas to understand which interventions can be shared among all training programs. Through the GEL Study, we aim to ensure resident readiness for practice as we understand, then optimize, the learning environment for trainees and staff.

Tularemia presenting as suspected necrotic arachnidism.

The true danger of the spider bite stems from misdiagnosis and resultant delay in proper treatment of entities that, unlike spider bites, are not self-limited. Obtaining a complete exposure and travel history is central to the development of an accurate and appropriate differential diagnosis.

Screening for colorectal cancer.

This review will comprise a general overview of colorectal cancer (CRC) screening. We will cover the impact of CRC, CRC risk factors, screening modalities, and guideline recommendations for screening in average-risk and high-risk individuals. Based on this data, we will summarize our approach to CRC screening.

Screening for prostate cancer.

This review comprises a general overview of the impact and risk factors for prostate cancer. Evidenced-based professional society prostate cancer screening guideline recommendations are reviewed, and our approach to a case is presented.

Screening for breast cancer.

This review will give a general overview of the impact of breast cancer, as well as breast cancer risk factors, identification of high-risk groups, screening modalities, and guidelines for screening average-risk and high-risk individuals, including a case discussion of the primary care provider's approach to screening.

Screening for lung cancer.

This review will comprise a general overview of the epidemiology of lung cancer, as well as lung cancer risk factors, screening modalities, current guideline recommendations for screening, and our approach to lung cancer screening.