Bradley H. Crotty

The availability and nature of physician information on the internet.

BackgroundAlthough patients are commonly using the Internet to find healthcare information, the amount of personal and professional physician information and patient-generated ratings freely accessible online is unknown.ObjectiveTo characterize the nature of online professional and personal information available to the average patient searching for physician information through a standardized web search.Design, Setting, and ParticipantsWe studied 250 randomly selected internal medicine physicians registered with the Massachusetts Board of Registration in Medicine in 2008. For each physician, standardized searches via the Google search engine were performed using a sequential search strategy. The top 20 search results were analyzed, and websites that referred to the study subject were recorded and categorized. Physician rating sites were further investigated to determine the number of patient-entered reviews.Main MeasuresNumber and content of websites attributable to specific physicians.Key ResultsWebsites containing personal or professional information were identified for 93.6% of physicians. Among those with any web sites identified, 92.8% had professional information and 32.4% had personal information available online. Female physicians were more likely to have professional information available on the Internet than male physicians (97.5% vs. 91.7%, p = 0.03), but had similar rates of available personal information (32.5% vs. 32.5%, p = ns). Among personal sites, the most common categories included social networking sites such as Facebook (10.8% of physicians), hobbies (10.0%), charitable or political donations (9.6%), and family information (8.8%). Physician rating sites were identified for 86.4% of providers, but only three physicians had more than five reviews on any given rating site.ConclusionsPersonal and professional physician information is widely available on the Internet, and often not under direct control of the individual physician. The availability of such information has implications for physician–patient relationships and suggests that physicians should monitor their online information.

Adoption of a wiki within a large internal medicine residency program: a 3-year experience.

OBJECTIVE To describe the creation and evaluate the use of a wiki by medical residents, and to determine if a wiki would be a useful tool for improving the experience, efficiency, and education of housestaff. MATERIALS AND METHODS In 2008, a team of medical residents built a wiki containing institutional knowledge and reference information using Microsoft SharePoint. We tracked visit data for 3 years, and performed an audit of page views and updates in the second year. We evaluated the attitudes of medical residents toward the wiki using a survey. RESULTS Users accessed the wiki 23,218, 35,094, and 40,545 times in each of three successive academic years from 2008 to 2011. In the year two audit, 85 users made a total of 1082 updates to 176 pages and of these, 91 were new page creations by 17 users. Forty-eight percent of residents edited a page. All housestaff felt the wiki improved their ability to complete tasks, and 90%, 89%, and 57% reported that the wiki improved their experience, efficiency, and education, respectively, when surveyed in academic year 2009-2010. DISCUSSION A wiki is a useful and popular tool for organizing administrative and educational content for residents. Housestaff felt strongly that the wiki improved their workflow, but a smaller educational impact was observed. Nearly half of the housestaff edited the wiki, suggesting broad buy-in among the residents. CONCLUSION A wiki is a feasible and useful tool for improving information retrieval for house officers.

Renal artery angiography: “The right ipsilateral oblique” Myth

Background: Finding the optimal image intensifier angle of obliquity during renal intervention is important for accurate stent placement but can require multiple catheter rotations and test injections of contrast. Objective: Explore the usefulness of axial magnetic resonance angiography (MRA) as a roadmap for predicting image intensifier position during subsequent renal intervention. Methods: MRA images were reviewed in 137 consecutive patients (255 renal arteries) undergoing workup for renal artery stenosis. The axial angle of renal artery incidence perpendicular to the spine was estimated by two operators and results averaged. Results: The average angle of incidence for the renal artery ostia was +21.24° ±2.31° for the right and +8.81° ±2.0° for the left (P < .0001). The positive numbers correlate with left anterior oblique (LAO) and negative right anterior oblique (RAO). Conclusions: MRA can be used to define the origin of the renal artery and is most likely to predict an LAO image window for subsequent angiography of the left and right renal arteries displacing the “ipsilateral oblique” axiom. In patients without baseline MRA the 10 to 20 degree LAO “empiric” position will allow coaxial imaging of both renal ostia in 75% of cases. However, there can be extreme variation in the renal origin (53° RAO to 85° LAO) and we advocate using the simple technique reported herein to define the renal origin in patients with pre‐procedure MRA.

Successful urgent endovascular surgery for symptomatic subclavian artery aneurysmal compression of the trachea.

The purpose of this study is to report the progress of a patient who entered the hospital with symptomatic tracheal compression from a large right subclavian artery aneurysm that was treated with a self‐expanding stent graft. The patient was at increased risk for traditional surgery, thus endovascular isolation of the aneurysm was felt to be reasonable. A flexible self‐expanding stent graft was placed via a brachial artery cutdown and common femoral access without complication. The symptoms improved and the patient remained asymptomatic at 2‐year follow‐up with serial CT scan confirmation of aneurysm regression. This unusual case illustrates that endovascular decompression of an aneurysm may have some benefit in alleviating subacute symptoms of extrinsic encroachment into other vital structures. Technical and clinical success was achieved with the stent graft deployment and this seems to be a reasonable alternative to surgery in such patients. Catheter Cardiovasc Interv 2005;64:291–295.

Preparing residents for future practice: report of a curriculum for electronic patient–doctor communication

Objectives Patients frequently use secure web portals to access their medical record and communicate with their doctors, though few institutions currently train residents for electronic communication. We sought to develop a curriculum for secure messaging between patients and resident physicians, and to assess resident attitudes before and after the curriculum. Methods In 2011, we developed a curriculum for patient–doctor secure messaging using a web-based patient portal within an internal medicine residency programme. We asked all residents to perform a self-assessment of skills, and report attitudes toward electronic communication at the beginning and end of the experience (9 months apart). We enrolled residents who practiced at the hospital-based clinic site into the patient portal, and recorded usage statistics. Results The completed survey response rate was 108/159 (68%). At baseline, 57% of residents had used traditional email with patients, and most residents felt that the portal would increase work for providers but benefit patients. Postintervention questionnaires demonstrated no significant changes among all respondents, but residents who used the portal perceived improvements in care. Most residents were concerned about professional liability. More residents felt comfortable writing electronic messages to patients after the curriculum (80% to 91%, p=0.01). Conclusions Implementing a patient web portal and secure messaging in a residency clinic is feasible and may improve the work and educational experience of trainees. Residents were initially sceptical of secure messaging being an additional burden to their work, but this was not realised among residents who used the portal.

Opening Residents' Notes to Patients: A Qualitative Study of Resident and Faculty Physician Attitudes on Open Notes Implementation in Graduate Medical Education.

Purpose OpenNotes is a growing national initiative inviting patients to read clinician progress notes (open notes) through a secure electronic portal. The goals of this study were to (1) identify resident and faculty preceptor attitudes about sharing notes with patients, and (2) assess specific educational needs, policy recommendations, and approaches to facilitate open notes implementation. Method This was a qualitative study using focus groups with residents and faculty physicians who supervise residents, representing primary care, general surgery, surgical and procedural specialties, and nonprocedural specialties, from Beth Israel Deaconess Medical Center and Geisinger Health System in spring 2013. Data were audio recorded and transcribed verbatim, then coded and organized into themes. Results Thirty-six clinicians (24 [66.7%] residents and 12 [33.3%] faculty physicians) participated. Four main themes emerged: (1) implications of full transparency, (2) note audiences and ideology, (3) trust between patients and doctors, and (4) time pressures. Residents and faculty discussed how open notes might yield more engaged patients and better notes but were concerned about the time needed to edit notes and respond to patient inquiries. Residents were uncertain how much detail they should share with patients and were concerned about the potential to harm the patient–doctor relationship. Residents and faculty offered several recommendations for open notes implementation. Conclusions Overall, participants were ambivalent about resident participation in open notes. Residents and faculty identified clinical and educational benefits to open notes but were concerned about potential effects on the patient–doctor relationship, requirements for oversight, and increased workload and burnout.

Confidentiality in the digital age

Digital technology introduces new concerns for confidentiality and information security. Bradley H Crotty and Arash Mostaghimi outline the regulations governing confidentiality and medical privacy and provide practical advice on how to safeguard patient information

Improving health care proxy documentation using a web-based interview through a patient portal

OBJECTIVE Health care proxy (HCP) documentation is suboptimal. To improve rates of proxy selection and documentation, we sought to develop and evaluate a web-based interview to guide patients in their selection, and to capture their choices in their electronic health record (EHR). METHODS We developed and implemented a HCP interview within the patient portal of a large academic health system. We analyzed the experience, together with demographic and clinical factors, of the first 200 patients who used the portal to complete the interview. We invited users to comment about their experience and analyzed their comments using established qualitative methods. RESULTS From January 20, 2015 to March 13, 2015, 139 of the 200 patients who completed the interview submitted their HCP information for their clinician to review in the EHR. These patients had a median age of 57 years (Inter Quartile Range (IQR) 45-67) and most were healthy. The 99 patients who did not previously have HCP information in their EHR were more likely to complete and then submit their information than the 101 patients who previously had a proxy in their health record (odds ratio 2.4, P = .005). Qualitative analysis identified several ways in which the portal-based interview reminded, encouraged, and facilitated patients to complete their HCP. CONCLUSIONS Patients found our online interview convenient and helpful in facilitating selection and documentation of an HCP. Our study demonstrates that a web-based interview to collect and share a patients HCP information is both feasible and useful.

Academic General Internal Medicine: A Mission for the Future

ABSTRACTAfter five decades of growth that has included advances in medical education and health care delivery, value cohesion, and integration of diversity, we propose an overarching mission for academic general internal medicine to lead excellence, change, and innovation in clinical care, education, and research. General internal medicine aims to achieve health care delivery that is comprehensive, technologically advanced and individualized; instills trust within a culture of respect; is efficient in the use of time, people, and resources; is organized and financed to achieve optimal health outcomes; maximizes equity; and continually learns and adapts. This mission of health care transformation has implications for the clinical, educational, and research activities of divisions of general internal medicine over the next several decades.

Successful treatment of iatrogenic renal artery perforation with an autologous vein-covered stent.

A 72‐year‐old woman developed severe flank pain associated with hemodynamic compromise immediately after a J‐curve guidewire was inadvertently advanced into the right renal artery during cardiac catheterization. Contrast extravasation consistent with perforation of the main renal artery was seen on abdominal angiography. The perforation was successfully sealed using a premounted coronary stent that was covered with an autologous antecubital vein. Wide stent patency without aneurismal dilatation was confirmed on a 2‐year follow‐up renal angiogram. Cathet Cardiovasc Intervent 2002;57:39–43.