Alfred Reid

Local Anesthesia for Circumcision: Which Technique Is Most Effective?

Background and Objectives: Circumcision is the most commonly performed surgical procedure in the United States, and it is painful. Several investigators have independently documented the reliability and safety of local anesthesia in eliminating the pain associated with circumcision. Investigations have not, however, been conducted to determine which technique is most effective in reducing the pain of the procedure. This study compares the techniques of local anesthesia for circumcision to determine which technique most safely and reliably reduces pain. Methods: Fifty-six infants being circumcised were randomly assigned to one of three groups according to anesthesia technique: (1) distal branch block, (2) root block, and (3) subpubic block. Change in heart rate and oxygen saturation, as well as cry response, were recorded. Heart rate and oxygen saturation differences were analyzed utilizing Students t test, whereas cry response was analyzed using the chi-square test. Results: We discontinued using the distal branch block technique during the study because we were concerned about possible untoward outcomes. As a result, only data from the circumcisions of the 42 infants who were assigned to the root block and subpubic block groups were analyzed. The dorsal penile nerve root block more reliably reduced the pain of circumcision than did the subpubic technique (P = 0.05). There were no serious complications with any of the techniques in this study. Conclusions: Compared with distal branch block and subpubic block techniques, nerve block at the penile root most reliably and safely eliminated the pain of circumcision.

Patient-centered outcomes for frequent headaches.

Objective.—To identify clinical outcomes that headache sufferers consider meaningful.

A randomized controlled trial of two different types of web-based instructional methods: one with case-based scenarios and one without.

Background: Computer-based learning (CBL) is an effective form of medical education. Educators have developed recommendations for instructional design but there is only minimal research that evaluates these recommendations. Aim: To evaluate the effect of case-based questions contained in computer modules on learning efficacy. Methods: The authors conducted a randomized controlled trial in 124 medical students of two CBL PowerPoint modules-based on Medicare. The modules were identical except one contained 11 case-based scenarios followed by multiple choice questions. The primary outcome measurement was a previously validated, 11-item knowledge test taken at the end of the module and at the end of the academic year to test retention. Results: The students who studied the module with case-based questions answered one more item correctly in the first test (8.9 vs. 10.00 correct answers, p = 0.001). This difference had disappeared by the time of the second test (4.2 vs. 4.7, p = 0.095). Conclusions: This study shows that computer modules with case-based questions enhance learning in the short-term but at the expense of increased time and so decreased learning efficiency. This learning benefit was not maintained.

Electronic Health Record Effects on Work-Life Balance and Burnout Within the I3 Population Collaborative

BACKGROUND Physician burnout is a problem that often is attributed to the use of the electronic health record (EHR). OBJECTIVE To estimate the prevalence of burnout and work-life balance satisfaction in primary care residents and teaching physicians, and to examine the relationship between these outcomes, EHR use, and other practice and individual factors. METHODS Residents and faculty in 19 primary care programs were anonymously surveyed about burnout, work-life balance satisfaction, and EHR use. Additional items included practice size, specialty, EHR characteristics, and demographics. A logistic regression model identified independent factors associated with burnout and work-life balance satisfaction. RESULTS In total, 585 of 866 surveys (68%) were completed, and 216 (37%) respondents indicated 1 or more symptoms of burnout, with 162 (75%) attributing burnout to the EHR. A total of 310 of 585 (53%) reported dissatisfaction with work-life balance, and 497 (85%) indicated that use of the EHR affected their work-life balance. Respondents who spent more than 6 hours weekly after hours in EHR work were 2.9 times (95% confidence interval [CI] 1.9-4.4) more likely to report burnout and 3.9 times (95% CI 1.9-8.2) more likely to attribute burnout to the EHR. They were 0.33 times (95% CI 0.22-0.49) as likely to report work-life balance satisfaction, and 3.7 times (95% CI 2.1-6.7) more likely to attribute their work-life balance satisfaction to the EHR. CONCLUSIONS More after-hours time spent on the EHR was associated with burnout and less work-life satisfaction in primary care residents and faculty.

Prediction of academic achievement in family medicine.

No abstract available.

Learnings From the Pilot Implementation of Mobile Medical Milestones Application.

BACKGROUND Implementation of the educational milestones benefits from mobile technology that facilitates ready assessments in the clinical environment. We developed a point-of-care resident evaluation tool, the Mobile Medical Milestones Application (M3App), and piloted it in 8 North Carolina family medicine residency programs. OBJECTIVE We sought to examine variations we found in the use of the tool across programs and explored the experiences of program directors, faculty, and residents to better understand the perceived benefits and challenges of implementing the new tool. METHODS Residents and faculty completed presurveys and postsurveys about the tool and the evaluation process in their program. Program directors were interviewed individually. Interviews and open-ended survey responses were analyzed and coded using the constant comparative method, and responses were tabulated under themes. RESULTS Common perceptions included increased data collection, enhanced efficiency, and increased perceived quality of the information gathered with the M3App. Residents appreciated the timely, high-quality feedback they received. Faculty reported becoming more comfortable with the tool over time, and a more favorable evaluation of the tool was associated with higher utilization. Program directors reported improvements in faculty knowledge of the milestones and resident satisfaction with feedback. CONCLUSIONS Faculty and residents credited the M3App with improving the quality and efficiency of resident feedback. Residents appreciated the frequency, proximity, and specificity of feedback, and faculty reported the app improved their familiarity with the milestones. Implementation challenges included lack of a physician champion and competing demands on faculty time.

Triple Aim Is Triply Tough: Can You Focus on Three Things at Once?

BACKGROUND AND OBJECTIVES The I3 POP Collaborative sought to improve health of patients attending North Carolina, South Carolina, and Virginia primary care teaching practices using the triple aim framework of better quality, appropriate utilization, and enhanced patient experience. We examined change in triple aim measures over 3 years, and identified correlates of improvement. METHODS Twenty-nine teaching practices representing 23 residency programs participated. The Institute for Health Care Improvement Breakthrough Series Collaborative model was tailored to focus on at least one triple aim goal and programs submitted data annually on all collaborative measures. Outcome measures included quality (chronic illness, prevention); utilization (hospitalization, emergency department visits, referrals) and patient experience (access, continuity). Participant interviews explored supports and barriers to improvement. RESULTS Six of 29 practices (21%) were unable to extract measures from their electronic health records (EHR). All of the remaining 23 practices reported improvement in at least one measure, with 11 seeing at least 10% improvement; seven (24%) improved measures in all three triple aim areas, with two experiencing at least 10% improvement. Practices with a greater number of patient visits were more likely to show improved measures (odds ratio [OR] 10.8, 95% confidence interval [CI]: .68-172.2, P=0.03). Practice interviews revealed that engaged leadership and systems supports were more common in higher performing practices. CONCLUSIONS Simultaneous attainment of improvement in all three triple aim goals by teaching practices is difficult. I3 POP practices that were able to pull and report data improved on at least one measure. Future work needs to focus on cultivating leadership and systems supporting large scale improvement.

Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home

PURPOSE Results of a study evaluating quality-of-care, financial, and patient satisfaction outcomes of pharmacist-conducted telehealth visits for diabetes management and warfarin monitoring are reported. METHODS A retrospective pre-post study was conducted to determine the impact of an electronic visit (e-visit) program targeting 2 groups of outpatients: adults with uncontrolled diabetes and warfarin-treated adults performing patient self-testing (PST) for monitoring of International Normalized Ratio (INR) values. RESULTS A total of 36 patients participated in the e-visit program during the 2-year study period. Among warfarin-treated patients, the percentage of INR values in the desired range increased relative to preenrollment values (from 62.5% to 72.7%, p = 0.07), and the frequency of extreme INR values (values of <1.5 or >5.0) decreased (from 4.8% to 0.01%, p = 0.01); the margin per patient was

Assessment of faculty development program outcomes.

300 during the first year and

Consent form readability in university-sponsored research.

191 annually thereafter. In the diabetes group, a decrease from baseline in glycosylated hemoglobin values of 3.4 percentage points was observed at 5.7 months after enrollment (p < 0.001), with significant improvements in frequencies of statin use, aspirin use, and blood pressure control; the margin was