Amitai Ziv

Utilization of physician offices by adolescents in the United States.

Recent guidelines for adolescent primary care call for the specification of clinical services by three adolescent age subgroups. Yet analyses of office visits have either merged adolescence into one stage or divided it at age 15 years. Objective. To explore the utilization of physician offices in the United States by early (11–14 years), middle (15–17 years), and late (18–21 years) adolescents. Design. Secondary analysis of the 1994 National Ambulatory Medical Care Survey, focusing on visits made by the three adolescent age groups. Setting. Nationally representative sample of 2426 physicians in nonfederal, nonhospital offices. Subjects. A total of 33 598 visits by patients of all ages, representing 681.5 million visits in 1994. Main Outcome Measures. Number of visits, health insurance, providers seen, duration of visits, reasons for visits, resulting diagnoses, and counseling provided. Results. Adolescents aged 11 to 21 years made 9.1% (61.8 million) of the total office visits and represented 15.4% of the total US population in 1994. This underrepresentation in visits held across all three adolescent age subgroups. Within the adolescent cohort, whites were overrepresented relative to their population proportion (78.5% of visits, 67.6% of population) and blacks and Hispanic adolescents were underrepresented (8.3% and 9.3% of visits, 15.5% and 13.1% of population). Middle adolescence signaled a life turning point from male to female predominance in office visits. Peak lifetime uninsurance rates occurred at middle adolescence for females (18.7%) and late adolescence for males (24.0%). Between childhood and early adolescence, public insurance decreased from 24.7% to 15.7% and uninsurance increased from 12.7% to 19.7%. Pediatricians accounted for the highest proportion of early adolescent visits (41.2%), family physicians for middle adolescent visits (35.3%), obstetrician-gynecologists for late adolescent female visits (37.3%), and family physicians for late adolescent male visits (34.8%). Mean visit duration during adolescence was 16 minutes, did not differ by age subgroup or sex, exceeded that of children (14.6 minutes), and was shorter than that of adults (19.3 minutes). Obstetrician-gynecologists spent more time with adolescents than did other physicians. Education or counseling was included in 50.4% of adolescent visits, ranging from 65.1% for obstetrician-gynecologists to 34.8% for internists. During early adolescence, the leading reasons for both male and female visits were respiratory (19.4%), dermatological (10.0%), and musculoskeletal (9.7%). A similar profile was found for middle and late adolescent males. For middle and late adolescent females, the leading reason for visits was special obstetrical-gynecological examination (12.8% and 21.1%), and the leading diagnosis resulting from visits was pregnancy (9.5% and 20.4%). Conclusions. Adolescents underutilize physician offices and are more likely to be uninsured than any other age group. Visits are short, and counseling is not a uniform component of care. As adolescents mature, their providers, presenting problems, and resulting diagnoses change. The data from the National Ambulatory Medical Care Survey support a staged approach to adolescent preventive services, targeted to the needs of three age subgroups.

Simulation Based Medical Education: an opportunity to learn from errors

Medical professionals and educators recognize that Simulation Based Medical Education (SBME) can contribute considerably to improving medical care by boosting medical professionals’ performance and enhancing patient safety. A central characteristic of SBME is its unique approach to making (and learning from) mistakes, which is regarded as a powerful educational experience and as an opportunity for professional improvement. The basic assumption underlying SBME is that increased practice in learning from mistakes and in error management in a simulated environment will reduce occurrences of errors in real life and will provide professionals with the correct attitude and skills to cope competently with those mistakes that could not be prevented. The main message of the present paper is that this assumption, which serves as the driving force of SBME, should also serve as a starting point for critical thinking and questioning regarding the multiple aspects and components of SBME. These questions, in turn, should lead to empirical research that will provide feedback concerning changes that may be necessary in order to attain the goal of improving medical professionals’ performance. Based on such research, SBME will be held accountable for its outcomes, i.e. whether its educational techniques indeed result in decreased occurrence of errors or not, and whether the ability to cope with the errors that do occur is significantly improved. The first of three issues that were addressed concerns individuals’ experience of performing mistakes. It is suggested that in order to benefit fully from the experience of performing mistakes in a simulated context, medical educators should create a balance between the emotional load associated with the experience and the professional lessons that can be learned. Furthermore, research should focus on the long-term effects of the experience in changing professionals’ attitudes and behaviour. The second question concerned the contribution of the different components of the educational experience to creating the desired changes in professionals’ performance. Analysis of the teaching and learning involved in each stage of the educational event should serve as the basis for research that aims at identifying the unique contribution and efficiency of each element, and defining the essential core activities of a simulated experience. Finally, the need to define a newly emerging profession—SBME educator—was addressed. The professional qualifications are, clearly, multidisciplinary and should be based on the growing experience of medical educators in training students and professionals. Defining the profession is essential in order to create academic environments in which professionals will be trained to develop and implement new programmes, accompanied by research and assessment.

Patient safety and simulation-based medical education

Continuous quality improvement is an accepted mandate in healthcare services. The delivery of the best, evidence based quality of care ultimately depends on the competences of practitioners as well as the system that supports their work. Medical education has been increasingly called upon to insure providers possess the skills and understanding necessary to fulfill the quality mission. Patient safety has in the past five years rapidly risen to the top of the healthcare policy agenda, and been incorporated into quality initiatives. Demand for curricula in patient safety and transfer of safety lessons learned in other risky industries have created new responsibilities for medical educators. Simulation based medical education will help fill these needs. Simulation offers ethical benefits, increased precision and relevance of training and competency assessment, and new methods of teaching error management and safety culture.Established and successful simulation methods such as standardized patients and task trainers are being joined by newer approaches enabled by improved technology.Continuous quality improvement is an accepted mandate in healthcare services. The delivery of the best, evidence based quality of care ultimately depends on the competences of practitioners as well as the system that supports their work. Medical education has been increasingly called upon to insure providers possess the skills and understanding necessary to fulfill the quality mission. Patient safety has in the past five years rapidly risen to the top of the healthcare policy agenda, and been incorporated into quality initiatives. Demand for curricula in patient safety and transfer of safety lessons learned in other risky industries have created new responsibilities for medical educators. Simulation based medical education will help fill these needs. Simulation offers ethical benefits, increased precision and relevance of training and competency assessment, and new methods of teaching error management and safety culture.Established and successful simulation methods such as standardized patients and task t...

Reliability and Validity of a Simulation-based Acute Care Skills Assessment for Medical Students and Residents

Background Medical students and residents are expected to be able to manage a variety of critical events after training, but many of these individuals have limited clinical experiences in the diagnosis and treatment of these conditions. Life-sized mannequins that model critical events can be used to evaluate the skills required to manage and treat acute medical conditions. The purpose of this study was to develop and test simulation exercises and associated scoring methods that could be used to evaluate the acute care skills of final-year medical students and first-year residents. Methods The authors developed and tested 10 simulated acute care situations that clinical faculty at a major medical school expects graduating physicians to be able to recognize and treat at the conclusion of training. Forty medical students and residents participated in the evaluation of the exercises. Four faculty members scored the students/residents. Results The reliability of the simulation scores was moderate and was most strongly influenced by the choice and number of simulated encounters. The validity of the simulation scores was supported through comparisons of students’/residents’ performances in relation to their clinical backgrounds and experience. Conclusion Acute care skills can be validly and reliably measured using a simulation technology. However, multiple simulated encounters, covering a broad domain, are needed to effectively and accurately estimate student/resident abilities in acute care settings.

Primary care physicians' use of an electronic medical record system: a cognitive task analysis.

OBJECTIVETo describe physicians’ patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient–doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular.DESIGNCognitive task analysis using semi-structured interviews and field observations.PARTICIPANTSTwenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel.RESULTSThe comprehensiveness, organization, and readability of data in the EMR system reduced physicians’ need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient’s chart. EMR use interfered with patient–doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians’ communication skills also helped.CONCLUSIONSThere is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians’ offices and by enhancing physicians’ computer and communication skills.

Improving Handoff Communications in Critical Care: Utilizing Simulation-Based Training Toward Process Improvement in Managing Patient Risk

BACKGROUND A patient admitted to the medical step-down unit experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff. METHODS Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process. This led to the development and implementation of a handoff protocol and the incorporation of handoff training into a simulation-based teamwork and communication workshop. A second round of observations took place 6 to 8 weeks following training. RESULTS The intervention demonstrated an increase in the incidence of nurses communicating crucial information during handoffs, including patient name, events that had occurred during the previous shift, and treatment goals for the next shift. However, there was no change in the incidence of checking the monitor alarms and the mechanical ventilator. CONCLUSIONS Simulation-based training can be incorporated into the risk management process and can contribute to patient safety practice.

Simulation in Medical Education: A Review

Simulation is used widely in medical education. The simulation methodologies used at the present time range from low technology to high technology. This article describes how role play, standardized patients, computer, videotape, and mannequin simulations are integrated into the educational curricula for medical students and physicians. Advantages and disadvantages of simulation and barriers to the use of simulation are discussed.

Incorporating simulation-based objective structured clinical examination into the Israeli National Board Examination in Anesthesiology.

We describe the unique process whereby simulation-based, objective structured clinical evaluation (OSCE) has been incorporated into the Israeli board examination in anesthesiology. Development of the examination included three steps: a) definition of clinical conditions that residents are required to handle competently, b) definition of tasks pertaining to each of the conditions, and c) incorporation of the tasks into hands-on simulation-based examination stations in the OSCE format, including 1) trauma management, 2) resuscitation, 3) crisis management in the operating room, 4) regional anesthesia, and 5) mechanical ventilation. Members of the Israeli Board of Anesthesiology Examination Committee assisted by experts from the Israel Center for Medical Simulation and from Israels National Institute for Testing and Evaluation were involved in this process and in the development of the assessment tools, orientation of examinees, and preparation of examiners. The examination has been administered 4 times in the past 2 yr to 104 examinees and has gradually progressed from being a minor part of the oral board examination to a prerequisite component of this test. The pass rate ranged from 70% in resuscitation to 91% in regional anesthesia. The mean inter-rater correlations for all the checklist items, for the score based on the critical checklist items only, and for the general rating were 0.89, 0.86, and 0.76, respectively. The overall Kappa coefficients (the inter-rater agreement coefficient) for the total score and the critical checklist items were 0.71 and 0.76, respectively. The correlation between the total score and the general score was 0.76. According to a subjective feedback questionnaire, most (70%–90%) participants found the difficulty level of the examination stations reasonable to very easy and prefer this method of examination to a conventional oral examination. The incorporation of OSCE-driven modalities in the certification of anesthesiologists in Israel is a continuing process of evaluation and assessment.

Using advanced simulation for recognition and correction of gaps in airway and breathing management skills in prehospital trauma care

In this prospective study, we used two full-scale prehospital trauma scenarios (severe chest injury and severe head injury) and checklists of specific actions, reflecting essential actions for a safe treatment and successful outcome, were used to assess performance of postinternship physician graduates of the Advanced Trauma Life Support (ATLS) course. In the first 36 participants, simulated training followed basic training in airway and breathing management, whereas in the next 36 participants, 45 min of simulative training in airway management using the Air-Man simulator (Laerdal, Norway) were added before performing the study scenarios. The content of training was based on common mistakes performed by participants of the first group. After the change in training, the number of participants not performing cricoid pressure or not using medication during intubation decreased from 55% (20 of 36) to 8% (3 of 36) and from 42% (15 of 36) to 11% (4 of 36), respectively (P < 0.05). The number of participants not holding the tube properly before fixation decreased from 28% (10 of 36) to 0% (0 of 36) (P < 0.05). In the severe head trauma scenario, performed by 15 of 36 participants in each group, the incidence of mistakes in the management of secondary airway or breathing problems after initial intubation decreased from 60% (9 of 15) to 0% (0 of 15) (P < 0.05). The present study highlights problems in prehospital trauma management, as provided by the ATLS course. It seems that graduates may benefit from simulation-based airway and breathing training. However, clinical benefits from simulation-based training need to be evaluated.

An acute care skills evaluation for graduating medical students: a pilot study using clinical simulation

Purpose  This investigation aimed to explore the measurement properties of scores from a patient simulator exercise.