Andrew R. Hoellein

Improving Students’ Sexual History Inquiry and HIV Counseling with an Interactive Workshop Using Standardized Patients

Sexual history and HIV counseling are essential clinical skills. Our project’s purpose was to evaluate a standardized patient (SP) educational intervention teaching third-year medical students sexual history taking and HIV counseling. A 4-hour SP workshop was delivered to one-half of the class. Four weeks later, all students engaged in an SP examination including one station on assessing sexual history taking and HIV counseling. Workshop participants scored one standard deviation higher on sexual history and HIV counseling items than nonparticipants. Our sexual history and HIV counseling curriculum was associated with students asking more thorough sexual histories and providing more HIV counseling.

Receipt of preventive health services by IBD patients is significantly lower than by primary care patients

Background: Persons with chronic diseases often do not receive preventive care at the same rate as the general population. Reasons for this are not clear. We conducted a cross‐sectional survey of patients with inflammatory bowel disease (IBD) and controls to assess receipt of 10 preventive health services. Methods: From March through October 2006, IBD outpatients and primary care outpatients at the University of Kentucky (UK) were surveyed by trained clinicians, using chart data to augment patient response. A second sample of IBD patients from the University of Chicago was studied with a self‐administered survey. Results: One hundred and seventeen IBD subjects were enrolled at UK, 125 IBD subjects were enrolled at UCH, and 100 control subjects were recruited from UK primary care clinics. The overall age‐/sex‐adjusted screening rate, as measured by the screening index, was significantly lower in UK IBD subjects than in UK controls (75.1% versus 83.9%, P = 0.0002). The UCH data showed a 67% overall age‐/sex‐adjusted screening rate. After adjusting for insurance status, the difference in screening rates was still lower for IBD patients than for controls (71% versus 78%; P = 0.022). Neither disease type nor disease control rating predicted screening rate. Conclusions: Our data suggest IBD patients do not receive preventive services at the same rate as general medical patients. Preventive care is a facet of global IBD management that deserves further study.

CAN PHYSICIANS IMPROVE PATIENT SATISFACTION WITH LONG WAITING TIMES

The purpose of our study was to determine how time spent with the physician might be related to patient dissatisfaction with their waiting time. During a 2-month period, patients in our internal medicine resident continuity clinic completed a survey assessing their satisfaction with their waiting time and their estimates of their waiting time and time spent with the resident physician. For patients with long waiting times (more than 15 min in the waiting room or more than 10 min in the exam room), patient dissatisfaction with waiting time was associated with a shorter physician visit (48% were dissatisfied if the physician spent less than 15 min vs. 18% if the physician spent more than 15 min with them, p = .03). These data suggest that physicians can mediate the negative effects of long waiting times by spending more time with their patients. Future studies on patient satisfaction should consider this interaction.

A needs assessment of complementary and alternative medicine education at the University of Kentucky College of Medicine.

Introduction: Complementary and alternative medicine (CAM) encompasses a wide variety of increasingly popular therapies not generally taught in allopathic medical schools but of apparent interest to medical trainees. However, little is known about the learners’ specific needs for improving their CAM clinical skills. Methods: Third-year medical students and internal medicine resident-physicians at the University of Kentucky were invited to participate in a voluntary questionnaire to assess CAM knowledge, skills, attitudes as well as their desired learning methods. Results: Medical students (n = 22) and resident-physicians (n = 39) generally hold favorable attitudes toward CAM but admit to significant knowledge deficits and do not feel adept at counseling their patients about CAM. Students indicate observation and hands-on experiences as their preferred pedagogy while residents favor textbooks, articles, and lectures to learn about CAM. Nevertheless, one resident noted, “any information in any format would be helpful as we get no teaching in this area”. Conclusions: In our sample, learner-driven CAM education at undergraduate and graduate levels is indeed necessary and wanted. In constructing CAM education interventions, attitudes, perceived knowledge deficits, and preferred learning strategies should be considered for the trainees and thus ultimately responsive to the needs of their patients.

Do pressure and fatigue influence resident job performance

Background: Global surveys of residents have consistently identified stress variables as important factors in resident job performance. Aims: Determine whether an association exists between resident stress and job performance. Method: Over a three month period, interns on our inpatient ward services were surveyed regarding their current call schedule, whether their prior nights sleep was sufficient, whether they felt pressed by other commitments, whether they spent enough time teaching medical students and whether they had completed all patient care issues on a given day. Multiple logistic regression was used to assess the association between call status, pressure and sleep adequacy with reported omissions in patient care and adequacy of teaching. Results: In the regression analysis, ratings of high pressure and insufficient sleep but not call status independently predicted outcomes. For example, if an intern felt both pressed and tired, they were over eight times more likely to omit a patient care issue and over four times more likely to report inadequate teaching. Conclusions: Subjective ratings of high pressure and insufficient sleep are associated with poor job performance in medical residents.

Are Continuity Clinic Patients Less Satisfied When Residents Have a Heavy Inpatient Workload

The purpose of this study was to assess the influence of resident nonclinic workload on the satisfaction of continuity clinic patients. Over a 2-month period in 2002, residents and patients were surveyed at the University of Kentucky internal medicine continuity clinic. Residents provided a self-report of their nonclinic workload as light or medium versus heavy or extremely heavy. Patient satisfaction was assessed with a 7-item, 10-point scale with items derived from commonly used patient satisfaction instruments. In 168 patient encounters, patients were significantly less satisfied with their clinic visit if they were seen by a resident who had a heavier workload. In addition, these patients gave significantly lower ratings with regard to the amount of time spent with the patient during the visit, and how well the resident listened and paid attention. Although alternative explanations exist, we propose that heavy hospital workload is associated with decreased patient satisfaction in resident continuity clinic.

Student involvement on teaching rounds.

Background Inpatient internal medicine education occurs in a fragile learning environment. The authors hypothesized that when medical students are involved in teaching rounds, residents may perceive a decrease in value of attending teaching. Method During two summer periods, trained research assistants shadowed teaching rounds, tracking patient census and team call status, recording basic content of rounds, and delivering a survey instrument to the learners, asking them to rate the quality of the attending’s teaching that day. Results One hundred sixty-six rounds were analyzed. Attending teaching ratings peaked when students were highly involved. In fact, high student involvement was an independent predictor of higher resident evaluation of teaching rounds (P < .0001). Conclusions The best teaching occurred when involvement of medical students was greatest and their involvement was not necessarily a zero-sum game. The authors conclude that attending investment in medical student education during teaching rounds benefits all members of the inpatient team.

Are continuity clinic patients less satisfied when the resident is postcall

Due to recent public debate and newly imposed resident work hour restrictions, we decided to investigate the relationship of resident call status to their ambulatory patients’ satisfaction. Resident continuity clinic patients were asked to rate their level of satisfaction on a 10-point Likert-type scale. Using multiple regression approaches, these data were then assessed as a function of resident call status. We found that in 646 patient encounters, patient satisfaction scores were significantly less when the resident was postcall, 8.99±1.8, than when not postcall, 9.31±1.3. We herein discuss etiologies and implications of these findings for both patient care and medical education.

End-of-life and palliative care curricula in internal medicine clerkships: A report on the presence, value and design of curricula as rated by clerkship directors

Purpose End-of-life and palliative care (EOL/PC) education is a necessary component of undergraduate medical education. The extent of EOL/PC education in internal medicine (IM) clerkships is unknown. The purpose of this national study was to investigate the presence of formal EOL/PC curricula within IM clerkships; the value placed by IM clerkship directors on this type of curricula; curricular design and implementation strategies; and related barriers and resources. Method The Clerkship Directors in Internal Medicine conducted its annual survey of its institutional members in April 2012. The authors analyzed responses to survey items pertaining to formal EOL/PC curriculum and content using descriptive statistics. The authors used qualitative techniques to analyze free-text responses. Results The response rate was 77.0% (94/122). Of those responding, 75.8% (69/91) believed such training should occur in the IM clerkship, and 43.6% (41/94) reported formal curricula in EOL/PC. Multiple instructional modalities were used to deliver this content, with the majority of programs dedicating four or more hours to the curriculum. Curricula covered a wide range of topics, and student assessment tools were varied. Most felt that students valued this education. The qualitative analysis revealed differences in the values clerkship directors placed on teaching EOL/PC within the IM clerkship. Conclusions Although many IM clerkship directors have implemented formal curricula in EOL/PC, a substantial gap remains between those who have implemented and those who believe it belongs in the clerkship. Time, faculty, cost, and competing demands are the main barriers to implementation.

Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis

OBJECTIVE Inconclusive findings about infection risks, importantly the use of immunosuppressive medications in patients who have undergone large-joint total joint arthroplasty, challenge efforts to provide evidence-based perioperative total joint arthroplasty recommendations to improve surgical outcomes. Thus, the aim of this study was to describe risk factors for developing a post-operative infection in patients undergoing TJA of a large joint (total hip arthroplasty, total knee arthroplasty, or total shoulder arthroplasty) by identifying clinical and demographic factors, including the use of high-risk medications (i.e., prednisone and immunosuppressive medications) and diagnoses [i.e., rheumatoid arthritis (RA), osteoarthritis (OA), gout, obesity, and diabetes mellitus] that are linked to infection status, controlling for length of follow-up. METHODS A retrospective, case-control study (N = 2212) using de-identified patient health claims information from a commercially insured, U.S. dataset representing 15 million patients annually (from January 1, 2007 to December 31, 2009) was conducted. Descriptive statistics, t-test, chi-square test, Fishers exact test, and multivariate logistic regression were used. RESULTS Male gender (OR = 1.42, p < 0.001), diagnosis of RA (OR = 1.47, p = 0.031), diabetes mellitus (OR = 1.38, p = 0.001), obesity (OR = 1.66, p < 0.001) or gout (OR = 1.95, p = 0.001), and a prescription for prednisone (OR = 1.59, p < 0.001) predicted a post-operative infection following total joint arthroplasty. Persons with post-operative joint infections were significantly more likely to be prescribed allopurinol (p = 0.002) and colchicine (p = 0.006); no significant difference was found for the use of specific disease-modifying anti-rheumatic drugs and TNF-α inhibitors. CONCLUSION High-risk, post-operative joint infection groups were identified allowing for precautionary clinical measures to be taken.