C. A. Feddock

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.

Enhancing Knowledge and Clinical Skills Through an Adolescent Medicine Workshop

OBJECTIVEnTo determine the effect of a medical school adolescent medicine workshop on knowledge and clinical skills using standardized patients.nnnDESIGNnRandomized controlled trial.nnnSETTINGnThe University of Kentucky College of Medicine, Lexington.nnnPARTICIPANTSnA total of 186 third-year medical students. Intervention Medical students assigned to the intervention group (n = 95) participated in a 4-hour adolescent medicine workshop using standardized patients to practice interviewing and counseling skills. Medical students assigned to the control group (n = 91) participated in an alternative workshop.nnnOUTCOME MEASURESnMedical student adolescent interviewing and counseling skills were assessed using adolescent standardized patient encounters during the end-of-clerkship examination and during the end of the third-year Clinical Performance Examination. Medical student knowledge was assessed at the end of the clerkship using an open-ended postencounter written exercise and the questions specific to adolescent medicine on the clerkship written examination.nnnRESULTSnBoth groups had comparable baseline characteristics. Medical students in the intervention group scored significantly higher on both measures of clinical skills, the standardized patient stations during the end-of-clerkship examination and the Clinical Performance Examination. Intervention medical students also scored significantly higher on both measures of knowledge, the open-ended postencounter written exercise and the written examination.nnnCONCLUSIONSnA brief adolescent medicine workshop using standardized patients improved medical students knowledge and skills at the end of a 4-week clerkship, and the improvement in clinical skills persisted at the end of the third year of medical school.

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.

Is time spent with the physician associated with parent dissatisfaction due to long waiting times

The objectives of this study were to assess the relationship between wait time and parent satisfaction and determine whether time with the physician potentially moderated any observed negative effects of long wait time. Data were collected from parents in a pediatric outpatient clinic. Parent satisfaction with the clinic visit was significantly negatively related to wait times. More time spent with the physician was positively related to satisfaction independent of wait times. Furthermore, among clinic visits with long wait times, more time with the physician showed a relatively strong positive relationship with parent satisfaction. Therefore, although long wait times was related to decreased parent satisfaction with pediatric clinic visits, increased time with the physician tended to moderate this relationship.

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.

In small skin abscesses, clindamycin or trimethoprim–sulfamethoxazole after incision and drainage increased cures

Question In children and adults with a small skin abscess, does adding clindamycin or trimethoprimsulfamethoxazole (TMP-SMX) after incision and drainage increase clinical cure rates? Methods Design Randomized placebo-controlled trial. ClinicalTrials.gov NCT00730028. Allocation Concealed.* Blinding Blinded* (patients and study staff). Follow-up period 7 to 10 days after treatment (primary outcome) and 1 month after treatment. Setting 6 centers in the USA. Patients 786 child and adult outpatients (mean age 26 y, 64% 18 years of age, 57% men) who had a single skin abscess (circumscribed and drainable pus) with greatest diameter 5 cm (4 cm in patients 1 to 8 y of age and 3 cm in those 6 to 11 mo of age) and 2 of the following signs or symptoms for 24 hours: erythema, tenderness, swelling or induration, local warmth, and purulent drainage. Exclusion criteria included BMI >40 kg/m2, oral temperature >38.5C (>38.0C in children 6 to 11 mo of age), abscess due to a human or animal bite, superficial skin infection, infection site with need for specialized management, surgical site or prosthetic device infection, systemic inflammatory response syndrome, immunocompromising condition or need for immunosuppressive therapy, need for hospitalization, use of systemic antistaphylococcal antibacterial therapy in the past 14 days, treatment for cancer or an inflammatory disorder in the past 12 months, or major surgery in the past 12 months. Intervention Clindamycin, two 150-mg tablets given 3 times/d (n =266); TMP-SMX, two 80-mg/400-mg tablets given twice/d plus 2 placebo tablets/d (n =263); or placebo, 2 tablets given 3 times/d (n =257) for 10 days after standardized incision and drainage. Drug doses were adjusted for weight in children. Outcomes Outcomes included clinical cure at 7 to 10 days after treatment (primary outcome) and at 1 month, and adverse events (AEs). Lack of clinical cure was defined as continued signs and symptoms of infection, skin infection at a new site or recurrence at original site, study drug discontinuation due to adverse effects at 48 hours, unplanned surgery for the skin infection, or infection-related hospitalization. Patient follow-up 88% at 7 to 10 days and 86% at 1 month after treatment (intention-to-treat-analysis). Main results 67% of patients had Staphylococcus aureus infection, and 49% had methicillin-resistant S aureus infection. The results for clinical cure are in the Table. Patients receiving clindamycin had more treatment-related AEs, mostly nonserious diarrhea, than those receiving TMP-SMX (22% vs 11%, P =0.001) or placebo (22% vs 12%, P =0.007). Conclusion In child and adult outpatients with small skin abscesses, adding clindamycin or trimethoprimsulfamethoxazole after incision and drainage increased clinical cure rates. Clindamycin (CLI) vs trimethoprimsulfamethoxazole (TMP-SMX) vs placebo after incision and drainage in children and adults with a small skin abscess Outcomes Event rates RBI (95% CI) NNT (CI) CLI TMP-SMX Placebo Clinical cure at 7 to 10 d after treatment 83% 69% 21% (10 to 34) 8 (5 to 15) 82% 69% 19% (8 to 32) 8 (5 to 19) 83% 82% 1.6% (6 to 10) Not significant Clinical cure at 1 mo after treatment 79% 63% 25% (12 to 41) 7 (5 to 13) 73% 63% 17% (4 to 32) 10 (6 to 43) 79% 73% 7.6% (2 to 19) Not significant Abbreviations defined in Glossary. RBI, NNT, and CI calculated from event rates in article. Commentary Clinicians often face the dilemma of whether to prescribe adjunctive antibiotics after incision and drainage of small, uncomplicated skin abscesses. Although the current Infectious Diseases Society of America guidelines recommend only incision and drainage (1), few high-quality studies have addressed the use of antibiotics in this population. A previous randomized controlled trial (RCT) found that TMP-SMX, dosed twice daily at 320 mg and 1600 mg, respectively, resulted in a higher cure rate than placebo (2). However, that trial was limited to patients >12 years of age and included patients with both small and large abscesses. Daum and colleagues addressed this key question in a well-designed RCT. Their outcomes were similar to those in the study by Talan and colleagues (2), with cure rates of about 70% in the placebo group and adjunctive antibiotics increasing rates to >80%. We can learn several lessons from the trial by Daum and colleagues. First, standard dosing of TMP-SMX seems to be as effective as higher doses for treating small abscesses. Second, the higher cure rate of antibiotics must be balanced with increased risk for antibiotic adverse effects. Although TMP-SMX and placebo had similar AE rates, clindamycin had nearly double the rate, mainly due to diarrhea (number needed to harm =11 compared with placebo). Finally, and perhaps more critical, most patients with small abscesses will be cured by incision and drainage alone. Therefore, routine use of antibiotics for all abscesses would likely contribute to antibiotic resistance without providing benefit for most patients. Which patients are unlikely to benefit from adjunctive antibiotics remains unclear. Future studies should examine whether patients with small abscesses (<2 cm) and/or minimal surrounding cellulitis can be safely treated with drainage alone.

STANDARDIZED PATIENT RATINGS PREDICT ACTUAL PATIENT SATISFACTION.: 381

students were asked to perform a focused physical examination. Trained SPs assessed performance using a binomial checklist; included pulmonary examination items were inspection, palpation, percussion, and auscultation. The 10-item checklist was designed by a panel of clinician educators. Total score was calculated on a scale of 100. Results: 150 MS-2 students and 163 MS-4 students completed the station. Overall, performance by MS-2 students was superior to that by MS 4 students (87% vs 79%). MS-2 student performance was also superior on items of the lung examination related to palpation and percussion (Table). Performance on the rest of the lung examination was not different (inspection and auscultation; see Table). Overall, both groups performed poorly on items related to examination of the anterior chest and focusing on the abnormal area. Conclusion: When examining a standardized patient with symptoms of pneumonia, the performance of second-year medical students was superior to fourth-year students on a comprehensive pulmonary examination. Whether the difference reflects better ‘‘test taking’’ skills by MS-2, better efficiency by MS-4, or erosion of clinical skills by experiences during the clerkships is unknown.

AN ADOLESCENT MEDICINE WORKSHOP USING STANDARDIZED PATIENTS INCREASES KNOWLEDGE AND IMPROVES SKILLS.: 368

age confirmed that the post-FCM group scored significantly higher than the pre-FCM group. The test group parameter estimate was 4.02 (p , .001). In this model, the step 1 score was also a significant predictor of step 2 score: parameter estimate 0.699 (p , .001). The model’s adjusted R was 0.5375. Conclusions: Both step 1 scores and the FCM course were independent and significant predictors of step 2 performance for medical students. A centrally developed curriculum integrating clinical and basic sciences is feasible for the third year of medical school and is associated with an improvement in standardized testing.