Jeannette M. Shorey

Acute Wernicke's Encephalopathy After Intravenous Infusion of High-Dose Nitroglycerin

Excerpt Thiamine serves as a cofactor for glucose metabolism in the glycolytic and pentose phosphate pathways. Its deficiency produces a nutritional neurologic disorder, the Wernicke-Korsakoff synd...

Ethanol Intoxication Complicating Intravenous Nitroglycerin Therapy

Excerpt Intravenous Nitroglycerin, occasionally in large doses, is increasingly being used for patients with unstable angina, variant angina, and left ventricular failure, and to control intraopera...

Evidence for validity of a survey to measure the learning environment for professionalism

Background: With the emphasis on professionalism in academic health settings, including recently added accreditation requirements for US medical schools, there is a need for a valid and feasible method to assess the learning environment for professionalism. Aim: This article describes the development and investigation of the validity of a brief measure, the learning environment for professionalism (LEP) survey, designed to assess medical student perceptions of professionalism among residents and faculty during clinical rotations. Method: Two successive cohorts of third-year medical students completed the 22-item LEP survey at the conclusion of clerkship rotations, providing a total of 902 responses for scale reliability and principal components factor analysis, as well as assessment of changes in scores over time and correlations with a related clerkship evaluation item. Results: The internal structure of the LEP survey was consistent with intended goals to assess both positive and negative professionalism behaviors. Acceptable internal consistency, sensitivity to change over time, and positive relationships between LEP scores and a concurrent measure of professionalism were observed. Conclusions: Use of the instrument could help identify clinical learning environments for professionalism that represent either best practices or areas in need of improvement, assess the impact of professionalism initiatives, and help satisfy accreditation requirements.

The Clinician‐Teacher in Managed Care Settings

Managed care has grown tremendously over the last decade.1 In 1985, there were fewer than 8 million members; in 1995, there were more than 53 million members. Increasing numbers of doctors are now working in managed care, and most new graduates of residency programs will spend their careers in capitated managed care practices. Ten years ago, we wrote about the benefits of affiliations between academic health centers and health maintenance organizations (HMOs).2 What was then an interesting idea now has become a necessity. Curricula in medical schools and residency training programs have begun to address the changes in medical practice, but they have not kept pace with managed care practice development. In fact, in many parts of the country academic institutions have been insulated from the changes in practice. The well-described gap between skills emphasized in residency training and those necessary for practice continues to widen.3–5 As a result, HMO medical directors consider the majority of primary care physicians to be “poorly qualified” for managed care practice.6 There is an alarming growth of physician dissatisfaction in practice. A recent study by the California Medical Association revealed the dimensions of the problem. On the basis of their current work experiences, nearly 40% of California primary care physicians under the age of 40 would not again choose careers in medicine. Physician claims for disability, another symptom of physician distress, are at an all time high. The majority of these discontented physicians attributed career dissatisfaction to negative experiences with managed care practice.7 Residency training program directors must ensure that their graduates do not suffer from these negative attitudes. Patients also express dissatisfaction that can be attributed to deficient training. When patients say that their doctors don’t listen, are rushed, devalue their opinions, and treat them like objects, they are indirectly criticizing the programs that have trained the doctors. These concerns reflect the current problems of primary care practice and medical education. Building excellent managed care practices that incorporate the training of future physicians can serve to correct these deficiencies. Learning to practice in real managed care sites—where residents and medical students interact with role models and participate in authentic clinical work—may be the best way to prepare doctors to provide high-quality care in a cost-effective manner and to take pride and pleasure in their work.8,9 In this article we will present the results of nearly 25 years of experience in the graduate medical education of primary care internists in one managed care organization, Harvard Pilgrim Health Care (HPHC, formerly Harvard Community Health Plan). We have chosen to describe our experience in depth rather than to survey the small number of programs that have addressed the challenge of teaching in managed care settings. We will present our view of the elements of clinical competence that excellent managed care practice requires. We will describe the roles of clinician-educators in HPHCs primary care program, and discuss the challenges they face in balancing clinical practice and teaching responsibilities. Finally, we will describe the value of graduate medical education to our organization, and the challenges that must be met in order to sustain training in a busy managed care setting.

Crystal clear or tin ear: how do medical students interpret derogatory comments about patients and other professionals?

Purpose To assess the learning environment at our medical school, third-year medical students complete an 11-item survey called the Learning Environment for Professionalism (LEP) at the end of each clerkship. The LEP survey asks about the frequency of faculty and resident professional and unprofessional behaviors that students observed; two of the items specifically address derogatory comments. This study used focus group methodology to explore how medical students interpret the derogatory comments they reported on the LEP survey. Methods Seven focus groups were conducted with 82 medical students after they completed the LEP survey. Analysis of focus group transcripts was performed to better understand the nature and meaning that students ascribe to derogatory comments. Results The study results provide insights into the types of derogatory comments that medical students heard during their clerkship rotations, why the comments were made and how they were interpreted. Emergent themes, labeled by the authors as 1) ‘onstage-offstage’, 2) ‘one bad apple’, and 3) ‘pressure cooker environment’, highlight the contextual aspects and understandings ascribed by students to the derogatory comments. Incidentally, students felt that the comments were not associated with fatigue, but were associated with cumulative stress and burn-out. Conclusions The results suggest students have a clear understanding of the nature of unprofessional comments made by role models during clerkships and point to important systems-related issues that could be leveraged to improve clinical learning environments.