Chayan Chakraborti

A Systematic Review of Teamwork Training Interventions in Medical Student and Resident Education

BackgroundTeamwork is important for improving care across transitions between providers and for increasing patient safety.ObjectiveThis review’s objective was to assess the characteristics and efficacy of published curricula designed to teach teamwork to medical students and house staff.DesignThe authors searched MEDLINE, Education Resources Information Center, Excerpta Medica Database, PsychInfo, Cumulative Index of Nursing and Allied Health Literature, and Scopus for original data articles published in English between January 1980 and July 2006 that reported descriptions of teamwork training and evaluation results.MeasurementsTwo reviewers independently abstracted information about curricular content (using Baker’s framework of teamwork competencies), educational methods, evaluation design, outcomes measured, and results.ResultsThirteen studies met inclusion criteria. All curricula employed active learning methods; the majority (77%) included multidisciplinary training. Ten curricula (77%) used an uncontrolled pre/post design and 3 (23%) used controlled pre/post designs. Only 3 curricula (23%) reported outcomes beyond end of program, and only 1 (8%) >6weeks after program completion. One program evaluated a clinical outcome (patient satisfaction), which was unchanged after the intervention. The median effect size was 0.40 (interquartile range (IQR) 0.29, 0.61) for knowledge, 0.38 (IQR 0.32, 0.41) for attitudes, 0.41 (IQR 0.35, 0.49) for skills and behavior. The relationship between the number of teamwork principles taught and effect size achieved a Spearman’s correlation of .74 (p = .01) for overall effect size and .64 (p = .03) for median skills/behaviors effect size.ConclusionsReported curricula employ some sound educational principles and appear to be modestly effective in the short term. Curricula may be more effective when they address more teamwork principles.

Methodological rigor of quality improvement curricula for physician trainees: a systematic review and recommendations for change.

Purpose To systematically determine whether published quality improvement (QI) curricula for physician trainees adhere to QI guidelines and meet standards for study quality in medical education research. Method The authors searched MEDLINE, EMBASE, CINAHL, and ERIC between 1980 and April 2008 for physician trainee QI curricula and assessed (1) adherence to seven domains containing 35 QI objectives, and (2) study quality using the Medical Education Research Study Quality Instrument (MERSQI). Results Eighteen curricula met eligibility criteria; 5 involved medical students and 13 targeted residents. Three curricula (18%) measured health care outcomes. Attitudes about QI were high, and many behavior and patient-related outcomes showed positive results. Curricula addressed a mean of 4.3 (SD 1.8) QI domains. Student initiatives included 38.2% [95% CI, 12.2%–64.2%] beginning student-level objectives and 23.0% [95% CI, −4.0% to 50.0%] advanced student-level objectives. Resident curricula addressed 42.3% [95% CI, 29.8%–54.8%] beginning resident-level objectives and 33.7% [95% CI, 23.2%–44.1%] advanced resident-level objectives. The mean (SD) total MERSQI score was 9.86 (2.92) with a range of 5 of 14 [total possible range 5–18]; 35% of curricula demonstrated lower study quality (MERSQI score ≤ 7). Curricula varied widely in quality of reporting, teaching strategies, evaluation instruments, and funding obtained. Conclusions Many QI curricula in this study inadequately addressed QI educational objectives and had relatively weak research quality. Educators seeking to improve QI curricula should use recommended curricular and reporting guidelines, stronger methodologic rigor through development and use of validated instruments, available QI resources already present in health care settings, and outside funding opportunities.

Sensitivity of superficial cultures in lower extremity wounds

BACKGROUND Superficial wound cultures are routinely used to guide therapy, despite a lack of clear supporting evidence. PURPOSE To conduct a systematic review of the correlation between superficial wound cultures and the etiology of skin and soft tissue infections. DATA SOURCES Medline, EMBASE, CINAHL, Scopus. STUDY SELECTION Articles published between January 1960 and August 2009 involving superficial wound cultures and deeper comparison cultures. DATA EXTRACTION Two reviewers independently searched for abstracted information pertaining to the microbiology of lower extremity wounds sufficient to calculate the sensitivity and specificity of superficial wound cultures versus comparison cultures. DATA SYNTHESIS Data pooled using a random-effects meta-analysis model. RESULTS Of 9032 unique citations, 8 studies met all inclusion criteria. Inter-rater reliability was substantial (Kappa = 0.78). Pooled test sensitivity for superficial wound swabs was 49% (95% confidence interval [CI], 37-61%], and specificity was 62% (95% CI, 51-74%). The pooled positive and negative likelihood ratios (LRs) were 1.1 (95% CI, 0.71-1.5) and 0.67 (95% CI, 0.52-0.82). The median number of isolates for surface cultures (2.7, interquartile range [IQR] 1.8-3.2) was not significantly different than that for comparison cultures, (2.2, IQR 1.7-2.9) (P = 0.75). CONCLUSION Few studies show a strong relationship between superficial wound swabs and deep tissue cultures, and the current data demonstrate poor overall sensitivity and specificity. The positive and negative LRs were found to provide minimal utility in influencing pretest probabilities. Results of this analysis show that wound cultures should not be used in lieu of local antibiograms to guide initial antibiotic therapies.

Corticosteroids in the Treatment of Alcohol-Induced Rhabdomyolysis

Rhabdomyolysis is a common condition with potentially devastating complications, including acute renal failure, arrhythmias, and death. The standard of care is to use supportive measures such as aggressive fluid repletion to prevent kidney injury and attenuate clinical symptoms. Besides fluid management, few therapeutic options are available for the treatment of acute rhabdomyolysis. As a result, acute and refractory cases remain difficult to manage. We report a case of alcohol-induced rhabdomyolysis that responded dramatically to high-dose corticosteroids. A 55-year-old man presented to the emergency department for evaluation of diffuse muscle pain, weakness, and darkening urine. On admission, his creatine kinase (CK) level was 50,022 U/L. Despite aggressive fluid repletion, his CK level continued to increase, peaking at 401,280 U/L with a concomitant increase in muscle pain and urine darkening. On administration of high-dose corticosteroids, clinical symptoms and CK levels improved dramatically, and the patient was discharged 36 hours later with complete resolution of muscle pain and weakness. Given their low toxicity profile, short-term high-dose corticosteroids may be a valid treatment option for recurrent rhabdomyolysis unresponsive to fluid repletion.

Multiple myeloma presenting as spinal cord compression: a case report

IntroductionSpinal cord compression is a potentially devastating condition that demands immediate attention. Efforts must be divided between addressing the symptoms of cord compression and identifying the precise etiology of the condition.Case presentationA 76-year-old Peruvian man presented to our emergency department for evaluation of the gradual onset of lower extremity weakness over one month, resulting in falls and a two day history of bladder and bowel incontinence. Surprisingly, the etiology of this case of spinal cord compression was found to be multiple myeloma presenting as a solid tumor.ConclusionWe report a case of a spinal cord mass resulting in symptoms of cord compression that was diagnosed when aspects of our patients initial magnetic resonance imaging scan did not correlate with disc herniation, which was the diagnosis with the greatest pretest probability.

Effects of implementing a protocol for arterial blood gas use on ordering practices and diagnostic yield

BACKGROUND The arterial blood gas (ABG) is a valuable and commonly used laboratory test. This prospective cohort study examined the variability of ABG ordering through the implementation of an evidence-based protocol. METHODS The study consisted of two 6-week periods. The protocol consisted of evidence-based and consensus opinion based indications for ABGs. In the first phase (initial 6 weeks), respiratory therapists recorded the indications for ABGs ordered by clinicians. In the second phase, all medical and surgical physicians were trained on the clinical rationale behind the protocol and were instructed to write the indication for each ABG with the order. Rates of ABGs/patient/day were measured in aggregate and per indication. Multivariate regression was used for adjusted comparisons between indications within the protocol. RESULTS After protocol implementation, there was a significant decrease in ABGs from 2158 to 1674 (p=0.001), and after adjusting for daily census, there was a significant decrease from 35.3 ABGs/100 patients/day to 26.5 ABGs/100 patients/day (p<0.001), with no change in mortality or demographic characteristics between the populations. The percent of ABGs with normal range values for pH, PaCO2, and PaO2 decreased from 13.3% to 9.6% after implementation (p<0.001). Multivariate analysis revealed a 14% decrease in daily ABGs (p=0.001), a 15% decrease in weaning trial ABGs (p=0.039), and a 15% increase in ABGs ordered following a change in minute ventilation (p=0.004). Cost minimization analysis estimated annual institutional savings to be

Features of successful academic hospitalist programs: Insights from the SCHOLAR (SuCcessful HOspitaLists in academics and research) project

87,565. CONCLUSIONS Implementation of an evidence based protocol for ABG use resulted in fewer ABGs/patient/day largely from reduction of routine, daily ABGs. Ordering patterns for ABGs appeared to shift towards more clinically appropriate/relevant indications. LEVEL OF EVIDENCE 2b.

A quality conundrum: Well done but not enough

BACKGROUND As clinical demands increase, understanding the features that allow academic hospital medicine programs (AHPs) to thrive has become increasingly important. OBJECTIVE To develop and validate a quantifiable definition of academic success for AHPs. METHODS A working group of academic hospitalists was formed. The group identified grant funding, academic promotion, and scholarship as key domains reflective of success, and specific metrics and approaches to assess these domains were developed. Self-reported data on funding and promotion were available from a preexisting survey of AHP leaders, including total funding/group, funding/full-time equivalent (FTE), and number of faculty at each academic rank. Scholarship was defined in terms of research abstracts presented over a 2-year period. Lists of top performers in each of the 3 domains were constructed. Programs appearing on at least 1 list (the SCHOLAR cohort [SuCcessful HOspitaLists in Academics and Research]) were examined. We compared grant funding and proportion of promoted faculty within the SCHOLAR cohort to a sample of other AHPs identified in the preexisting survey. RESULTS Seventeen SCHOLAR programs were identified, with a mean age of 13.2 years (range, 6-18 years) and mean size of 36 faculty (range, 18-95). The mean total grant funding/program was

Effectiveness of teaching quality improvement to clinicians: a systematic review.

4 million (range,

Teaching evidence-based medicine using team-based learning in journal clubs.

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