Jeanne M. Farnan

Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards

User-created content and communications on Web-based applications, such as networking sites, media sharing sites, or blog platforms, have dramatically increased in popularity over the past several years, but there has been little policy or guidance on the best practices to inform standards for the professional conduct of physicians in the digital environment. Areas of specific concern include the use of such media for nonclinical purposes, implications for confidentiality, the use of social media in patient education, and how all of this affects the publics trust in physicians as patient-physician interactions extend into the digital environment. Opportunities afforded by online applications represent a new frontier in medicine as physicians and patients become more connected. This position paper from the American College of Physicians and the Federation of State Medical Boards examines and provides recommendations about the influence of social media on the patient-physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician-physician communication that preserve confidentiality while best using these technologies.

A Systematic Review: The Effect of Clinical Supervision on Patient and Residency Education Outcomes

Purpose To summarize the literature regarding the effect of clinical supervision on patient and educational outcomes, especially in light of the recent (2010) Accreditation Council for Graduate Medical Education report that recommends augmented supervision to improve resident education and patient safety. Method The authors searched the English-language literature from 1966 to 2010 using electronic databases and a hand search. They included studies that described a controlled design, and they have relayed the effects of supervision on patient- and education-related outcomes. Two authors abstracted prescribed data from the reviewed studies. The authors rated the quality of each study using the Medical Education Research Study Quality Instrument. Results Twenty-four articles across a variety of specialties (i.e., psychiatry, emergency medicine, surgery, anesthesia, and internal medicine) met inclusion criteria. Studies demonstrated that enhanced supervision in already-supervised activities resulted in improved patient- or education-related outcomes. Studies were limited by small sample sizes, nonrandomized designs, and a lack of objective measures of clinical supervision. Conclusions Enhanced clinical supervision of trainees has been associated with improved patient- and education-related outcomes in published studies. Future work should focus on developing validated measures of the effects of clinical supervision.

Hand-off Education and Evaluation: Piloting the Observed Simulated Hand-off Experience (OSHE)

AimThe Observed Simulated Hand-off Experience (OSHE) was created to evaluate medical students’ sign-out skills using a real-time assessment tool, the Hand-off CEX.SettingThirty-two 4th year medical students participated as part of an elective course.Program descriptionOne week following an interactive workshop where students learned effective hand-off strategies, students participated in an experience in which they performed a hand-off of a mock patient using simulated history and physical examination data and a brief video.Program evaluationInternal medicine residents served as standardized hand-off receivers and were trained on expectations. Students were provided feedback using a newly developed Hand-off CEX, based on the “Mini-CEX,” which rates overall hand-off performance and its components on a 9-point Likert-type scale. Outcomes included performance ratings and pre- and post-student self-assessments of hand-off preparedness. Data were analyzed using Wilcoxon signed-rank tests and descriptive statistics. Resident receivers rated overall student performance with a mean score of 6.75 (range 4–9, maximum 9). Statistically significant improvement was observed in self-perceived preparedness for performing an effective hand-off (67% post- vs. 27% pre-reporting ‘well-prepared,’ p < 0.009).DiscussionThis brief, standardized hand-off training exercise improved students’ confidence and was rated highly by trained observers. Future work focuses on formal validation of the Hand-off CEX instrument.

The YouTube Generation: Implications for Medical Professionalism

While medical education has remained relatively constant over the past century, the rising popularity of internet-based technologies, such as applications for social networking, media sharing, or blogging, has drastically changed the way in which physicians-in-training interact with educators, peers, and the outside world. The implementation of these new technologies creates new challenges and opportunities for medical educators. Representation, the absence of established policies and legal precedents, and the perception of the lay public exemplify some of the issues that arise when considering the digital images used by trainees. While some of these issues affect higher education generally, medical schools are faced with additional challenges to ensure that graduates exemplify the ideals of medical professionalism. We present a case vignette with subsequent discussion to highlight the complexities of ensuring medical professionalism in the digital age.

Resident uncertainty in clinical decision making and impact on patient care: a qualitative study

Background: Little is known regarding how internal medicine residents manage uncertainty during decision making and subsequent effects on patient care. The aims of this study were to describe types of uncertainty faced by residents, strategies employed to manage uncertainty and effects on patient care. Methods: Using critical incident technique, residents were asked to recall important clinical decisions during a recent call night, with probes to identify decisions made during uncertainty. They were also asked to report who they approached for advice. Three authors independently coded transcripts using the constant comparative method. Results: The 42/50 (84%) interviewed residents reported 18 discrete critical incidents. Six categories emerged and mapped to the domains of the Beresford Model of Clinical Uncertainty: technical uncertainty (procedural skills, knowledge of indications); conceptual uncertainty (care transitions, diagnostic decision making and management conflict) and personal uncertainty (goals of care). In managing uncertainty, residents report a “hierarchy of assistance”, using colleagues and literature for initial management, followed by senior residents, specialty fellows and, finally, the attending physician. Barriers to seeking the attending physician’s input included the existence of a defined hierarchy for assistance and fears of losing autonomy, revealing knowledge gaps, and “being a bother”. For 12 of the 18 cases reported, patient care was compromised: delay in procedure or escalation of care (n = 8); procedural complications (n = 2); and cardiac arrest (n = 2). Conclusion: Resident uncertainty results in delays of indicated care and, in some cases, patient harm. Despite the presence of a supervisory figure, residents adhere to a hierarchy when seeking advice in clinical matters.

Third-year medical students' participation in and perceptions of unprofessional behaviors.

Background Students’ perceptions of and participation in unprofessional behaviors may change during clinical clerkships. Method Third-year students anonymously reported observation, participation, and perceptions of 27 unprofessional behaviors before and five months after clerkships. Results Student observation (21 of 27) and participation (17 of 27) in unprofessional behaviors increased (P < .05). Students perceived unprofessional behaviors as increasingly appropriate (P < .05 for six behaviors). Participation in unprofessional behaviors was associated with diminished likelihood of perceiving a behavior as unprofessional (P < .05 for nine behaviors). Conclusions Student observation and participation in unprofessional behaviors increased during clerkships. Participation in unprofessional behaviors is associated with perceiving these behaviors as acceptable.

Searching for the missing pieces between the hospital and primary care: mapping the patient process during care transitions

Background Safe patient transitions depend on effective communication and a functioning care coordination process. Evidence suggests that primary care physicians are not satisfied with communication at transition points between inpatient and ambulatory care, and that communication often is not provided in a timely manner, omits essential information, or contains ambiguities that put patients at risk. Objective Our aim was to demonstrate how process mapping can illustrate current handover practices between ambulatory and inpatient care settings, identify existing barriers and facilitators to effective transitions of care, and highlight potential areas for quality improvement. Methods We conducted focus group interviews to facilitate a process mapping exercise with clinical teams in six academic health centres in the USA, Poland, Sweden, Italy, Spain and the Netherlands. Findings At a high level, the process of patient admission to the hospital through the emergency department, inpatient care, and discharge back in the community were comparable across sites. In addition, the process maps highlighted similar barriers to providing information to primary care physicians, inaccurate or incomplete information on referral and discharge, a lack of time and priority to collaborate with counterpart colleagues, and a lack of feedback to clinicians involved in the handovers. Conclusions Process mapping is effective in bringing together key stakeholders and makes explicit the mental models that frame their understanding of the clinical process. Exploring the barriers and facilitators to safe and reliable patient transitions highlights opportunities for further improvement work and illustrates ideas for best practices that might be transferrable to other settings.

Care transitions for hospitalized patients.

Ensuring safe care transitions is a core part of hospital medicine. These transitions include inpatient-outpatient transitions and in-hospital transitions. To ensure safe care during these transitions, clinicians should be aware of the types of transitions and the way in which these transitions can impede safe patient care. With this knowledge, strategies to ensure patient safety during care transitions can be adopted and training directed at teaching physicians safe hands-off practices could be developed and supported.

On-call supervision and resident autonomy: from micromanager to absentee attending.

D T M i y f t n 1984, Libby Zion, an 18-year-old woman, died in New York hospital of what was determined to be an dverse drug reaction; the grand jury investigating er death found contributing causes to be resident xhaustion and inadequate supervision. Although the esulting media spotlight focused on duty hour reglations, little attention has been paid to formalizing r regulating supervision provided to physicians-inraining. Despite subsequent revision of the New ork State health code mandating reduced work ours and increased clinical supervision, little effect as been observed in the amount and quality of esident supervision, especially in the overnight peiod when residents are often admitting new atients. In addition to preventing resident fatigue, providng adequate supervision is a fundamental aspect of nsuring safe patient care in teaching hospitals. Atending physicians in a supervisory capacity may be eld accountable for patient outcomes; an on-call apacity may be sufficient to establish a patient– hysician relationship and duty to supervise. Given hat they employ physicians-in-training for clinical are, sponsoring hospitals may be held vicariously iable for adverse outcomes caused by residents actng in accordance with their job description. As a esult of the duty hour regulations, many programs

Understanding communication during hospitalist service changes: A mixed methods study

BACKGROUND Little data exist to inform hospitalist communication during service changes. OBJECTIVE To characterize hospitalist handoffs during service changes. DESIGN Serial survey study. SETTING Single academic medical center. MEASUREMENTS From May to December 2007, 60 service changes among 17 hospitalists on a nonteaching service were targeted for evaluation using an anonymous 18-item survey that was completed by hospitalists within 48 hours of assuming care for patients. Survey items assessed completeness of handoff communication, certainty of patient care plans, missed information, time spent recovering information, and near misses/adverse events due to incomplete handoffs. The association between completeness of communication and handoff outcomes was examined. Narrative comments were analyzed qualitatively. RESULTS Ninety-three percent (56/60) of surveys were returned. All 17 hospitalists participated. Thirteen percent of respondents reported incomplete handoffs and 18% were uncertain of care plan on transition day. At least 1 near miss, attributable to incomplete communication was reported by 16%. Hospitalists who reported incomplete handoffs were more likely to report uncertainty about patient care plans on the transition day (71% incomplete vs. 10% complete, P < 0.01), discovery of missing information (71% incomplete vs. 24% complete, P = 0.01), near misses/adverse events (57% incomplete vs. 10% complete, P < 0.01), and more time resolving issues arising from missed information (71% incomplete vs. 22% complete, P < 0.01). Qualitative comments suggest the need for a more systematic, focused, team-based, and patient-centered handoff model. CONCLUSIONS Incomplete handoffs during service changes are associated with uncertainty and potential patient harm. Suggestions to improve the completeness of hospitalist service change communications are offered.