Gabriel T. Bosslet

The Patient–Doctor Relationship and Online Social Networks: Results of a National Survey

ABSTRACTBACKGROUNDThe use of online social networks (OSNs) among physicians and physicians-in-training, the extent of patient–doctor interactions within OSNs, and attitudes among these groups toward use of OSNs is not well described.OBJECTIVETo quantify the use of OSNs, patient interactions within OSNs, and attitudes toward OSNs among medical students (MS), resident physicians (RP), and practicing physicians (PP) in the United States.DESIGN/SETTINGA random, stratified mail survey was sent to 1004 MS, 1004 RP, and 1004 PP between February and May 2010.MEASUREMENTSPercentage of respondents reporting OSN use, the nature and frequency of use; percentage of respondents reporting friend requests by patients or patients’ family members, frequency of these requests, and whether or not they were accepted; attitudes toward physician use of OSNs and online patient interactions.RESULTSThe overall response rate was 16.0% (19.8% MS, 14.3% RP, 14.1% PP). 93.5% of MS, 79.4% of RP, and 41.6% of PP reported usage of OSNs. PP were more likely to report having visited the profile of a patient or patient’s family member (MS 2.3%, RP 3.9%, PP 15.5%), and were more likely to have received friend requests from patients or their family members (MS 1.2%, RP 7.8%, PP 34.5%). A majority did not think it ethically acceptable to interact with patients within OSNs for either social (68.3%) or patient-care (68.0%) reasons. Almost half of respondents (48.7%) were pessimistic about the potential for OSNs to improve patient–doctor communication, and a majority (79%) expressed concerns about maintaining patient confidentiality.CONCLUSIONPersonal OSN use among physicians and physicians-in-training mirrors that of the general population. Patient–doctor interactions take place within OSNs, and are more typically initiated by patients than by physicians or physicians-in-training. A majority of respondents view these online interactions as ethically problematic.

Nurse-Administered Propofol Sedation: Feasibility and Safety in Bronchoscopy

Background: Propofol is a fast-acting intravenous sedative that has advantages as a procedural sedative over traditional regimens. It has been shown to have a similar safety profile to traditional sedating medications in the setting of gastroenterologic endoscopy. Nurse-administered propofol sedation is given by a specially-trained nurse, without anesthesiologist involvement. Objectives: We have used nurse-administered propofol sedation in our bronchoscopy suite for several years. In this report, we summarize our experience with nurse-administered propofol sedation, and demonstrate it to be feasible and safe for bronchoscopic procedures. Methods: Procedure reports and nursing notes for 588 bronchoscopic procedures performed between July 2006 and June 2008 were retrospectively reviewed. Patient demographics, procedure type and indication, procedure time, medication doses, and adverse events were noted and analyzed. Results: Nurse-administered propofol sedation was used in 498/588 (85%) procedures. Patients utilizing nurse-administered propofol sedation had an average age of 53 years (range 18–86) with an average weight of 80 kg. 56% of the patients were male, and 57% of the procedures were performed on outpatients. Average procedure duration was 25 min (range 3–123). The average propofol dose was 3.13 mg/kg (range 0.12–20 mg/kg). Adverse events attributable to sedation were noted in 33 (6.6%) procedures. Of the 14 (2.8%) major adverse events (death, need for intubation, ICU stay, or hospitalization), only 6 (1.2%) were potentially attributable to the sedation regimen. There were 2 deaths, neither of which was related to sedation. Conclusions: Nurse-administered propofol sedation is a feasible and safe sedation method for bronchoscopic procedures.

Factors Associated With Family Satisfaction With End-of-Life Care in the ICU: A Systematic Review

BACKGROUND Family satisfaction with end-of-life care in the ICU has not previously been systematically reviewed. Our objective was to perform a review, synthesizing published data identifying factors associated with family satisfaction with end-of-life care in critically ill adult populations. METHODS The following electronic databases were searched: MEDLINE (Medical Literature Analysis and Retrieval System Online), MEDLINE Updated, EMBASE (Excerpta Medical Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycInfo, and PubMed. Two authors reviewed retrieved titles and abstracts. Studies describing nonadult and non-ICU populations or not addressing end-of-life care, family satisfaction, or factors affecting satisfaction were excluded. The remaining articles underwent full review and data extraction by two authors. Quality was assessed using a checklist based on the recommendations of the Consolidated Standards for Reporting Trials group. RESULTS The search yielded 1,072 articles, with 23 articles describing 14 studies meeting inclusion criteria. All studies obtained satisfaction data from family members via surveys and structured interviews. Specific communication strategies increasing satisfaction included: expressions of empathy, nonabandonment, and assurances of comfort and provision of written information. Additionally, support for shared decision-making, family presence at time of death, and specific patient-care measures such as extubation before death were associated with increased satisfaction. CONCLUSIONS Good-quality communication, support for shared decision-making, and specific patient-care measures were associated with increased satisfaction with end-of-life care. Assessing the familys desire to participate in shared decision-making may also be an important factor. Few interventions increased satisfaction. Future research is needed to further define optimal communication strategies, understand effective integration of palliative care into the ICU, and define significant score changes in survey instruments.

Original Research: Critical CareFactors Associated With Family Satisfaction With End-of-Life Care in the ICU

BACKGROUND Family satisfaction with end-of-life care in the ICU has not previously been systematically reviewed. Our objective was to perform a review, synthesizing published data identifying factors associated with family satisfaction with end-of-life care in critically ill adult populations. METHODS The following electronic databases were searched: MEDLINE (Medical Literature Analysis and Retrieval System Online), MEDLINE Updated, EMBASE (Excerpta Medical Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycInfo, and PubMed. Two authors reviewed retrieved titles and abstracts. Studies describing nonadult and non-ICU populations or not addressing end-of-life care, family satisfaction, or factors affecting satisfaction were excluded. The remaining articles underwent full review and data extraction by two authors. Quality was assessed using a checklist based on the recommendations of the Consolidated Standards for Reporting Trials group. RESULTS The search yielded 1,072 articles, with 23 articles describing 14 studies meeting inclusion criteria. All studies obtained satisfaction data from family members via surveys and structured interviews. Specific communication strategies increasing satisfaction included: expressions of empathy, nonabandonment, and assurances of comfort and provision of written information. Additionally, support for shared decision-making, family presence at time of death, and specific patient-care measures such as extubation before death were associated with increased satisfaction. CONCLUSIONS Good-quality communication, support for shared decision-making, and specific patient-care measures were associated with increased satisfaction with end-of-life care. Assessing the familys desire to participate in shared decision-making may also be an important factor. Few interventions increased satisfaction. Future research is needed to further define optimal communication strategies, understand effective integration of palliative care into the ICU, and define significant score changes in survey instruments.

Reason-Giving and Medical Futility: Contrasting Legal and Social Discourse in the United States with the United Kingdom and Ontario, Canada

Disputes regarding life-prolonging treatments are stressful for all parties involved. These disagreements are appropriately almost always resolved with intensive communication and negotiation. Those rare cases that are not require a resolution process that ensures fairness and due process. We describe three recent cases from different countries (the United States, United Kingdom, and Ontario, Canada) to qualitatively contrast the legal responses to intractable, policy-level disputes regarding end-of-life care in each of these countries. In so doing, we define the continuum of clinical and social utility among different types of dispute resolution processes and emphasize the importance of public reason-giving in the societal discussion regarding policy-level solutions to end-of-life treatment disputes. We argue that precedential, publicly available, written rulings for these decisions most effectively help to move the social debate forward in a way that is beneficial to clinicians, patients, and citizens. This analysis highlights the lack of such rulings within the United States.

The influence of the residency application process on the online social networking behavior of medical students: A single institutional study

Purpose To evaluate medical students’ behavior regarding online social networks (OSNs) in preparation for the residency matching process. The specific aims were to quantify the use of OSNs by students to determine whether and how these students were changing OSN profiles in preparation for the residency application process, and to determine attitudes toward residency directors using OSNs as a screening method to evaluate potential candidates. Method An e-mail survey was sent to 618 third- and fourth-year medical students at Indiana University School of Medicine over a three-week period in 2012. Statistical analysis was completed using nonparametric statistical tests. Results Of the 30.1% (183/608) who responded to the survey, 98.9% (181/183) of students reported using OSNs. More than half, or 60.1% (110/183), reported that they would (or did) alter their OSN profile before residency matching. Respondents’ opinions regarding the appropriateness of OSN screening by residency directors were mixed; however, most respondents did not feel that their online OSN profiles should be used in the residency application process. Conclusions The majority of respondents planned to (or did) alter their OSN profile in preparation for the residency match process. The majority believed that residency directors are screening OSN profiles during the matching process, although most did not believe their OSN profiles should be used in the residency application process. This study implies that the more medical students perceive that residency directors use social media in application screening processes, the more they will alter their online profiles to adapt to protect their professional persona.

Integration of Palliative Care Services in the Intensive Care Unit: A Roadmap for Overcoming Barriers

Clinicians working in the intensive care unit (ICU) confront death and dying daily. ICU care can be inconsistent with a patients values, preferences, and previously expressed goals of care. Current evidence promotes the integration of palliative care services within the ICU setting. Palliative care bridges the gap between comfort and cure, and these services are growing in the United States. This article discusses the benefits and barriers to integration of ICU and palliative care services, and a stepwise approach to implementation of palliative care services. Integration of palliative care services into ICU workflow is increasingly seen as essential to providing high-quality, comprehensive critical care.

Twelve tips for just in time teaching of communication skills for difficult conversations in the clinical setting

Abstract The ability to communicate well with patients and other members of the healthcare team is a vital skill for physicians to have, but one that is often not emphasized in medical education. Learners of all levels can obtain and develop good communication skills regardless of their natural ability in this area, and the clinical setting represents an underutilized resource to accomplish this task. With this in mind, we have reviewed the growing body of literature on the subject and organized our findings into twelve tips to help educators capitalize on these missed opportunities. While our emphasis is helping learners with difficult discussions, these tips can be easily adapted to any other clinical encounter requiring clear communication. Teaching effective communication skills in the clinical setting requires some extra time, but the steps outlined should not take more than a few minutes to complete. Taking the time to develop these skills in our learners will make a significant difference not only their lives but also their patients and their families.

Multicenter Validation of a Customizable Scoring Tool for Selection of Trainees for a Residency or Fellowship Program. The EAST-IST Study

Rationale: Few data have been published regarding scoring tools for selection of postgraduate medical trainee candidates that have wide applicability. Objectives: The authors present a novel scoring tool developed to assist postgraduate programs in generating an institution‐specific rank list derived from selected elements of the U.S. Electronic Residency Application System (ERAS) application. Methods: The authors developed and validated an ERAS and interview day scoring tool at five pulmonary and critical care fellowship programs: the ERAS Application Scoring Tool‐Interview Scoring Tool. This scoring tool was then tested for intrarater correlation versus subjective rankings of ERAS applications. The process for development of the tool was performed at four other institutions, and it was performed alongside and compared with the “traditional” ranking methods at the five programs and compared with the submitted National Residency Match Program rank list. Results: The ERAS Application Scoring Tool correlated highly with subjective faculty rankings at the primary institution (average Spearmans r = 0.77). The ERAS Application Scoring Tool‐Interview Scoring Tool method correlated well with traditional ranking methodology at all five institutions (Spearmans r = 0.54, 0.65, 0.72, 0.77, and 0.84). Conclusions: This study validates a process for selecting and weighting components of the ERAS application and interview day to create a customizable, institution‐specific tool for ranking candidates to postgraduate medical education programs. This scoring system can be used in future studies to compare the outcomes of fellowship training.

CEASE: A Guide for Clinicians on How to Stop Resuscitation Efforts

Resuscitation programs such as Advanced Cardiac Life Support, Cardiac Life Support, Pediatric Advanced Life Support, and the Neonatal Resuscitation Program offer inadequate guidance to physicians who must ultimately decide when to stop resuscitation efforts. These decisions involve clinical and ethical judgments and are complicated by communication challenges, group dynamics, and family considerations. This article presents a framework, summarized in a mnemonic (CEASE: Clinical Features, Effectiveness, Ask, Stop, Explain), for how to stop resuscitation efforts and communicate that decision to clinicians and ultimately the patients family. Rather than a decision rule, this mnemonic represents a framework based on best evidence for when physicians are considering stopping resuscitation efforts and provides guidance on how to communicate that decision.