B. Graeme Fincke

Morbidity and mortality conference: A survey of academic internal medicine departments

This study sought to determine the prevalence and characteristics of morbidity and mortality conferences (M&MCs) in U.S. internal medicine training programs. Two hundred ninety-five of 416 (71%) surveys were returned. Ninety percent of programs have an M&MC. Most meet monthly, have a designated leader, and entail case discussions of 3 or fewer patients. Cases are selected on the basis of unexpected bad outcomes, teaching value, and to a lesser extent, suspected medical error. Two thirds of the sites use M&MCs to meet administrative requirements for quality assurance. M&MC, while prevalent in internal medicine training programs, has a heterogeneity of focus. Hence, the goals and role of the conference, as judged by this survey, do not appear to be well defined and may warrant further clarification.

Potentially inappropriate prescribing in elderly veterans: Are we using the wrong drug, wrong dose, or wrong duration?

Objectives: To identify the extent of inappropriate prescribing using criteria for proper use developed by the Agency for Healthcare Research and Quality (AHRQ) and dose‐limitation criteria defined by Beers, as well as to describe duration of use and patient characteristics associated with inappropriate prescribing for older people.

Medical Residents' First Clearly Remembered Experiences of Giving Bad News

CONTEXT: Communication of bad news to patients or families is a difficult task that requires skill and sensitivity. Little is known about doctors’ formative experiences in giving bad news, what guidance they receive, or what lessons they learn in the process.OBJECTIVE: To learn the circumstances in which medical residents first delivered bad news to patients or families, the nature of their experience, and their opinions about how best to develop the needed skills.DESIGN: Confidential mailed survey.SETTING AND SUBJECTS: All medicine house officers at 2 urban, university-based residency programs in Boston.MAIN OUTCOME MEASURES: Details of medical residents’ first clearly remembered experiences of giving bad news to a patient or family member; year in training; familiarity with the patient; information about any planning prior to, observation of, or discussion after their first experience; and the usefulness of such discussions. We also asked general questions about delivering bad news, such as how often this was done, as well as asking for opinions about actual and desired training.RESULTS: One hundred twenty-nine of two hundred thirteen surveys (61%) were returned. Most (73%) trainees first delivered bad news while a medical student or intern. For this first experience, most (61%) knew the patient for just hours or days. Only 59% engaged in any planning for the encounter. An attending physician was present in 6 (5%) instances, and a more-senior trainee in 14 (11%) others. Sixty-five percent of subjects debriefed with at least 1 other person after the encounter, frequently with a lesser-trained physician or a member of their own family. Debriefing focused on the reaction of those who were given the bad news and the reaction of the trainee. When there were discussions with more-senior physicians, before or after the encounter, these were judged to be helpful approximately 80% of the time. Most subjects had given bad news between 5 and 20 times, yet 10% had never been observed doing so. Only 81 of 128 (63%) had ever observed an attending delivering bad news, but those who did found it helpful 96% of the time. On 7-point scales, subjects rated the importance of skills in delivering bad news highly, (mean 6.8), believed such skill can be improved (mean 6.6), and thought that more guidance should be offered to them during such activity (mean 5.8).CONCLUSION: Medical students and residents frequently deliver bad news to patients and families. This responsibility begins early in training. In spite of their inexperience, many do not appear to receive adequate guidance or support during their earliest formative experiences.

Gender Disparities in Lipid-Lowering Therapy Among Veterans With Diabetes

PURPOSE We sought to compare lipid-lowering therapy among female and male veterans with diabetes and hyperlipidemia. METHODS We conducted a cross-sectional study of veterans serviced by the Veterans Health Administration in 2006 who had both diabetes and hyperlipidemia and compared all female patients to age- and facility-matched males. We compared proportions of patients with any prescription for lipid-lowering therapy in the year and, among those with elevated low-density lipoprotein cholesterol (LDL >100 mg/dL) and no prior treatment, we compared initiation of lipid-lowering therapy. We used multiple logistic regression to estimate odds ratios (AOR) and 95% confidence intervals (CI), adjusting for race, VA eligibility, health care utilization, cardiovascular diseases, mental health conditions, and a comprehensive list of other comorbidities. We also performed the analysis stratified by age. FINDINGS Women had higher LDL levels than men (110 ± 38 vs. 101 ± 36 mg/dL) and were less likely to be receiving lipid-lowering therapy (80% vs. 84%; AOR, 0.79; 95% CI, 0.76-0.82) or to be initiated on such therapy (37% vs. 42%; AOR, 0.82; 95% CI, 0.74-0.90). Differences were greatest in the youngest women (<45 years old) for both any lipid-lowering therapy (61% vs. 75%; AOR, 0.50; 95% CI, 0.45-0.56) and initiation of therapy (26% vs. 38%; AOR, 0.55; 95% CI, 0.42-0.73). Adjustment for potential confounders did not change the risk estimates. CONCLUSION Women veterans with diabetes and hyperlipidemia receive less aggressive lipid-lowering therapy than men, especially among younger age groups. This disparity is of concern, because early intervention to control hyperlipidemia can reduce the later burden of cardiovascular disease among diabetic women.

Does Diabetes Care Differ by Type of Chronic Comorbidity?: An evaluation of the Piette and Kerr framework

OBJECTIVE To evaluate the relationship between diabetes care and types of comorbidity, classified by the degree to which their treatment is concordant with that for diabetes. RESEARCH DESIGN AND METHODS Retrospective cohort study (fiscal year [FY] 2001 to FY 2004) of 42,826 veterans with new-onset diabetes in FY 2003. Veterans were classified into five chronic comorbid illness groups (CCIGs): none, concordant only, discordant only, both concordant and discordant, and dominant. Five diabetes-related care measures were assessed in FY 2004 (guideline-consistent testing and treatment goals for HbA1c and LDL cholesterol and diabetes-related outpatient visits). Analyses included logistic regressions adjusting for age, race, sex, marital status, priority code, and interaction between CCIGs and visit frequency. RESULTS Only 20% of patients had no comorbidities. Mean number of visits per year ranged from 7.8 (no CCIG) to 17.5 (dominant CCIG). In unadjusted analyses, presence of any illness was associated with equivalent or better care. In the fully adjusted model, we found interaction between CCIG and visit frequency. When visits were <7 per year, the odds of meeting the goal of HbA1c <8% were similar in the concordant (odds ratio 0.96 [95% CI 0.83–1.11]) and lower in the discordant (0.90 [0.81–0.99]) groups compared with the no comorbidity group. Among patients with >24 visits per year, these odds were insignificant. Dominant CCIG was associated with substantially reduced care for glycemic control for all visit categories and for lipid management at all but the highest visit category. CONCLUSIONS Our study indicates that diabetes care varies by types of comorbidity. Concordant illnesses result in similar or better care, regardless of visit frequency. Discordant illnesses are associated with diminished care: an effect that decreases as visit frequency increases.

Co‐teaching: a faculty development strategy

It has been stated that faculty development programmes which are closely linked to particular teaching contexts are most likely to be effective. Over the past 10 years we have developed a model of ‘co‐teaching’ for faculty development which is based upon this premise and which can be applied to any clinical rotation. In this paper we describe our model, in which paired physicians focus on developing their teaching skills while sharing the clinical supervision of residents and medical students. Through iterative phases of teaching, debriefing and planning, co‐teachers gain experience in analysing teaching encounters and develop skills in self‐evaluation. Teaching occurs in the usual clinical settings such as attending (consultant) teaching rounds, clinic precepting, and case conferences. We discuss our model in the context of educational theory and related literature. We support our positive assessment of the co‐teaching model through the precepts of collaborative inquiry and case study methodology. Vignettes, taken from the experiences of the authors, are used to demonstrate how the model is used to develop effective solutions to problems and to help in the maturation of one’s skill as an educator. Successful implementation of the model is predicated on the development of a truly collaborative process between co‐teachers. We share lessons we have learned from our experience of implementing the model in different clinical venues, such as the contrast between teaching on a hospital ward or in the clinic. This collaborative process has been well received by junior and senior faculty participants in our institution for more than a decade.

Primary care and health outcomes among older patients with diabetes.

OBJECTIVE The aim of this study was to measure the relationship between days spent waiting for primary care and health outcomes among patients diagnosed with diabetes, especially among the elderly population. DATA SOURCE Secondary data from VA administrative databases and Medicare claims. STUDY DESIGN This is a retrospective observational study. Outcome variables include primary care utilization, mortality, heart attack, stroke, and ambulatory-care sensitive condition (ACSC) hospitalization. The main explanatory variable of interest is VA primary care wait time. Negative binomial models predict utilization and stacked logistic regression models predict the probability of experiencing each health outcome. Models are stratified by the presence of a selected health condition and age. PRINCIPAL FINDINGS Longer wait times were predicted to decrease utilization between 2 and 4 percent. There was no significant relationship between wait times and health outcomes for the overall sample. In stratified analyses, longer waits were associated with undesirable outcomes for those over age 70 with one of the selected health conditions or in certain narrower 5-year age groups, but the overall pattern of results does not indicate a systematic and significant effect. CONCLUSIONS There was a modest effect of long wait times on primary care utilization but no robust effect of longer wait times on health outcomes. Waiting for care did not significantly compromise long-term health outcomes for veterans with diabetes.

Patient, Primary Care Provider, and Specialist Perspectives on Specialty Care Coordination in an Integrated Health Care System

Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists—that is, the specialty care “triad.” This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and endocrinologists relied on interclinician relationships to coordinate care. Clinicians rarely included patients or other staff in their conceptualization of specialty care coordination. Patients often assumed responsibility for specialty care coordination but struggled to succeed. We identified several opportunities to improve coordination across the triad. In an integrated medical system, the shared organizational structure can facilitate these efforts.