Bennett Vogelman

The Postantibiotic Effect

Excerpt Suppression of bacterial growth that persists after short exposure of organisms to antimicrobial agents has been seen since early investigations with penicillin. For example, Parker and Lus...

Kinetics of antimicrobial activity

Assessment of antimicrobial activity from standard in vitro minimum inhibitory and minimum bactericidal concentration determinations alone is incomplete. Rate of bacterial killing, effect of increasing concentration, sub-MIC effects, and degree of suppression of bacterial growth after limited exposure (post-antibiotic effect) more precisely describe the course of antimicrobial activity. Aminoglycoside antibiotics exhibit concentration-dependent bactericidal activity and a prolonged post-antibiotic effect. beta-Lactam antibiotics demonstrate more time-dependent killing and lack post-antibiotic effects, except with staphylococci. Most bacteriostatic antimicrobial agents also produce post-antibiotic suppression of growth. Studies in different animal infection models with a variety of organisms suggest that beta-lactams are more efficacious with continuous dosing, whereas the efficacy of aminoglycosides is relatively independent of dosing regimen, even when administered once daily. Knowledge of the kinetics of antimicrobial action is useful in predicting optimal dosage regimens.

Creating Champions for Health Care Quality and Safety

Patient safety and quality of care are public concerns that demand personal responsibility at all levels of the health care organization. Senior residents in our graduate medical education program took responsibility for a capstone quality improvement project designed to transform them into champions for health care quality. Residents (n = 26) participated alone or in pairs in a 1-month faculty-mentored rotation at the Veterans Administration Hospital during the 2007-2008 academic year. They completed a Web-based curriculum, identified a quality-of-care issue, applied Plan—Do—Study—Act cycles, authored a report, and engaged colleagues in their innovations during a department-wide presentation. Results indicated that residents demonstrated significantly enhanced knowledge and attitudes about patient safety and quality improvement and provided consistently positive faculty and rotation evaluations. In addition, residents generated 20 quality improvement project proposals with a 50% rate of hospital-wide implementation, leading to meaningful changes in the systems that affect patient care.

Resident Self-Assessment and Self-Reflection: University of Wisconsin-Madison’s Five-Year Study

BACKGROUNDChart review represents a critical cornerstone for practice-based learning and improvement in our internal medicine residency program.OBJECTIVETo document residents’ performance monitoring and improvement skills in their continuity clinics, their satisfaction with practice-based learning and improvement, and their ability to self-reflect on their performance.DESIGNRetrospective longitudinal design with repeated measures.PARTICIPANTSEighty Internal Medicine residents abstracted data for 3 consecutive years from the medical records of their 4,390 patients in the University of Wisconsin-Madison (UW) Hospital and Clinics and William S. Middleton Veterans Administration (VA) outpatient clinics.MEASUREMENTLogistic modeling was used to determine the effect of postgraduate year, resident sex, graduation cohort, and clinic setting on residents’ “compliance rate” on 17 nationally recognized health screening and chronic disease management parameters from 2003 to 2007.RESULTSResidents’ adherence to national preventive and chronic disease standards increased significantly from intern to subsequent years for administering immunizations, screening for diabetes, cholesterol, cancer, and behavioral risks, and for management of diabetes. Of the residents, 92% found the chart review exercise beneficial, with 63% reporting gains in understanding about their medical practices, 26% reflecting on specific gaps in their practices, and 8% taking critical action to improve their patient outcomes.CONCLUSIONSThis paper provides support for the feasibility and practicality of this limited-cost method of chart review. It also directs our residency program’s attention in the continuity clinic to a key area important to internal medicine training programs by highlighting the potential benefit of enhancing residents’ self-reflection skills.

Changing Concepts and New Applications of Antibiotic Pharmacokinetics

Antibiotics with high protein binding have a lower percentage of free drug available for tissue penetration than antibiotics with lower protein binding. High protein binding, however, may have a beneficial effect on drug distribution. The smaller volume of distribution and reduced glomerular filtration of highly bound agents result in higher serum levels that are sustained longer. Although intermittent and continuous dosing regimens produce similar areas under the concentration-versus-time curves for serum and tissue, intermittent dosing produces higher peak and potentially earlier effective antibiotic levels at the site of infection. The excretion of certain antibiotic agents in the bile may be related to hepatic protein binding, high molecular weight, or unique structural features. Biliary excretion is important not only for bile concentrations but also for dosage modification. Antibiotics with dual elimination by the kidney and biliary tract require minimal dosage modification unless there is concomitant hepatic and renal dysfunction. The third-generation cephalosporins provide good examples of how protein binding, tissue penetration, and excretory mechanisms can be used to alter pharmacokinetics advantageously.

Commitment to change in graduate medical education

Context and setting The University of WisconsinMadison’s Internal Medicine Programme structures each resident’s semi-annual review as a series of chapters authored jointly by the resident and the programme director. Residents self-assess their growth in the Accreditation Council for Graduate Medical Education (ACGME) competencies (professionalism, communication, medical knowledge, practice-based learning and improvement, systems-based practice, patient care), evaluate their career development and professional–personal life balance, reflect on their strengths and gaps, and identify goals, objectives, tasks and monitoring strategies for selfimprovement. Then, during a 1-hour conversation with a programme director, residents align their opinions of their performance with multi-source evaluations (patients, peers, faculty) and prioritise specific commitments to change. Why the idea was necessary The commitment to change (CTC) strategy has been linked to improved medical practices in continuing medical education. Doctors who attend training and commit to a behavioural change later demonstrate improvements in practice compared with those who do not commit to change. Adoption of the CTC strategy during graduate medical education might similarly reduce the gap between residents’ performance on the competencies and the programme’s standards for best practices. What was done We recently formalised our semiannual review process by asking residents to document three self-selected and two externally driven (i.e. patient outcome core measure and patient safety) commitments to change. Residents also categorised progress on each of their prior goals as completed, not completed or not addressed at the end of residency. We analysed the content of residents’ commitments, the types of advice summarised in directors’ follow-up letters, and progress toward completion of residents’ commitments across 3 years of semi-annual reviews for our class of 27 residents who graduated in 2008. Evaluation of results and impact Career issues, followed by a desire to increase medical knowledge, dominated residents’ commitments. Residents effectively identified their competency gaps, allowing programme directors to target the low-hanging fruit, the high yield, and important areas with advice on how to identify mentors, prioritise goals and break down objectives into actionable tasks. Conversations necessarily revolved around externally driven, programme-specific competencies, organisational requirements (American Board of Internal Medicine, ACGME, Joint Commission on the Accreditation of Healthcare Organizations), fellowship and job seeking, which all residents eventually met. However, directors also consistently pushed residents to clarify their commitments within the internally driven areas of personal–professional balance, professionalism, communication and patient care. Outcome analyses indicated that residents were more successful at meeting externally driven patient safety (72%) and core measure (57%) commitments than at meeting internally driven commitments (32%). Yet, by acknowledging significant progress on their internally driven commitments, which are more difficult to change (e.g. communication, professionalism, reflective practice, teaching) during the semi-annual review, residents and programme directors were able to effectively enrich the conversation and, over 3 years, make the trainees more effective in achieving their goals. In summary, commitment to change practices help our residents complete the full cycle of critical reflection. Residents increase their skills in selfassessment, identifying their gaps and carrying out actionable plans with measurable outcomes. We believe that by structuring the semi-annual review in this way, we are generating internally driven doctors who will critically reflect, continuously improve and sustain their behavioural commitments over time.

Development and preliminary evaluation of the resident coordinated-transitional care (RC-TraC) program: A sustainable option for transitional care education.

ABSTRACT Older adults often face poor outcomes when transitioning from hospital to home. Although physicians play a key role in overseeing transitions, there is a lack of practice-based educational programs that prepare resident physicians to manage care transitions of older adults. An educational intervention to provide residents with real-life transitional care practice was therefore developed—Resident-coordinated Transitional Care (RC-TraC). RC-TraC adapted the evidence-based Coordinated-Transitional Care (C-TraC) nurse role for residents, providing opportunities to follow patients during the peri-hospital period without additional costs to the residency program. Between July 2010 and June 2013, 31 internal medicine residents participated in RC-TraC, caring for 721 patients. RC-TraC has been a sustainable, low-cost, practice-based education experience that is recognized as transitional care education by residents and continues in operation to this day. RC-TraC is a promising option for geriatric-based transitional care education of resident physicians and could also be adapted for nonphysician learners.

Successful Implementation of a Direct Observation Program in an Ambulatory Block Rotation

BACKGROUND Direct observation of clinical skills is a cornerstone of competency-based education and training. Ensuring direct observation in a consistent fashion has been a significant challenge for residency programs. OBJECTIVE The purpose of this study was to evaluate the effects of a novel evaluation system, designed to achieve ongoing direct observation of residents, examine changes in resident observation practices, and understand faculty attitudes toward direct observation and the evaluation system. METHODS Internal medicine residents on an ambulatory block rotation participated in a new evaluation system, which replaced a single end-of-rotation summative evaluation with 9 formative evaluations based on direct observation. Faculty received training in direct observation and use of the forms, and residents were given responsibility to collect 9 observations per rotation. Faculty members contacted residents at the beginning and middle of the rotation to ensure completion of the observations. Residents and faculty also completed postrotation surveys to gauge the impact of the new system. RESULTS A total of 507 patient encounters were directly observed, and 52 of 57 (91%) residents completed all 9 observations. Residents reported considerably more direct observation than prior to the intervention, and most reported changes to their clinical skills based on faculty feedback. Faculty reported improvements in their attitudes, increased their use of direct observation, and preferred the new system to the old one. CONCLUSIONS A novel evaluation system replacing summative evaluations with multiple formative evaluations based on direct observation was successful in achieving high rates of observations, and improving faculty attitudes toward direct observation.