Jo Shapiro

The Reliability of the Assessment of Endoscopic Laryngeal Findings Associated With Laryngopharyngeal Reflux Disease

Objective To determine the reliability of the assessment of laryngoscopic findings potentially associated with laryngopharyngeal reflux disease (LPRD).

Dysphagia and Aspiration with Unilateral Vocal Cord Immobility: Incidence, Characterization, and Response to Surgical Treatment

To objectively determine the incidence of dysphagia associated with unilateral vocal cord immobility (UVCI) and to evaluate the potential for response to vocal cord medialization, we made videofluoroscopic swallowing (VFS) recordings of patients with newly diagnosed UVCI and prospectively analyzed them in a blinded fashion using the Penetration-Aspiration Scale (PAS) and pharyngeal transport function measures. A subset of patients underwent vocal cord medialization and were evaluated with a postoperative VFS study. Comparison was made between preoperative and postoperative VFS results to study the effects of vocal cord medialization in this setting. Eighty-seven VFS recordings were studied in 64 adult patients with UVCI; 23 patients underwent VFS testing before and after vocal cord medialization. The UVCI was most commonly left-sided (53 cases) and most commonly resulted from thoracic or cardiac surgery (53.1%), followed by malignancy (15.6%). Overall, the median PAS score was 2.0 (25th-75th percentiles, 1.0–5.0), with 20 patients (31.3%) and 15 patients (23.4%) exhibiting penetration or aspiration, respectively. No significant differences in swallowing function were noted between surgical and nonsurgical causes of paralysis (PAS scores of 2.0 and 2.0, respectively; p = .901). The median PAS score improved from 4.0 to 3.0 (p = .395, Wilcoxon paired samples test) in patients studied after undergoing a vocal cord medialization procedure (6 laryngoplasties and 17 vocal cord injections). Laryngoplasty was not more successful than vocal cord injection in resolving aspiration (p = .27). Radiographically significant penetration or aspiration occurs in approximately one third of patients with UVCI, independent of the cause of paralysis. Vocal cord medialization may not be as effective as thought for eliminating aspiration in these patients.

Physicians' Needs in Coping With Emotional Stressors: The Case for Peer Support

OBJECTIVE To design an evidence-based intervention to address physician distress, based on the attitudes toward support among physicians at our hospital. DESIGN, SETTING, AND PARTICIPANTS A 56-item survey was administered to a convenience sample (n = 108) of resident and attending physicians at surgery, emergency medicine, and anesthesiology departmental conferences at a large tertiary care academic hospital. MAIN OUTCOME MEASURES Likelihood of seeking support, perceived barriers, awareness of available services, sources of support, and experience with stress. RESULTS Among the resident and attending physicians, 79% experienced either a serious adverse patient event and/or a traumatic personal event within the preceding year. Willingness to seek support was reported for legal situations (72%), involvement in medical errors (67%), adverse patient events (63%), substance abuse (67%), physical illness (62%), mental illness (50%), and interpersonal conflict at work (50%). Barriers included lack of time (89%), uncertainty or difficulty with access (69%), concerns about lack of confidentiality (68%), negative impact on career (68%), and stigma (62%). Physician colleagues were the most popular potential sources of support (88%), outnumbering traditional mechanisms such as the employee assistance program (29%) and mental health professionals (48%). Based on these results, a one-on-one peer physician support program was incorporated into support services at our hospital. CONCLUSIONS Despite the prevalence of stressful experiences and the desire for support among physicians, established services are underused. As colleagues are the most acceptable sources of support, we advocate peer support as the most effective way to address this sensitive but important issue.

The educational impact of ACGME limits on resident and fellow duty hours: a pre-post survey study.

Purpose To assess the educational impact of Accreditation Council for Graduate Medical Education resident work-hour limits implemented in July 2003. Method All trainees in all 76 accredited programs at two large teaching hospitals were surveyed between May and June 2003 (before work-hour reductions) and then between May and June 2004 (after work-hour reductions) about hours, education, and fatigue. Based on changes in weekly duty hours, 13 programs experiencing substantial reduction in hours were classified into a reduced-hours group. Differences in assessments of educational endpoints before and after policy implementation by trainees in the reduced-hours group were compared with those in other programs to control for potential temporal trends, using two-way ANOVA with interaction. Results The number of respondents was 1,770 (60% response rate). The reduced-hours group reported a significant decrease in time spent directly caring for patients (from 48.5 to 42.3 mean h/wk, P = 0.03), but the volume of important clinical experiences, including procedures, was preserved, as was the sense of clinical preparedness. On 22 questions related to educational quality and adequacy, only three differences in differences were significant, with the reduced-hours group reporting a relative increase in opportunities for research, decrease in quality of faculty teaching, and decrease in educational satisfaction. The percentage of trainees reporting frequent negative effects of fatigue dropped more in the reduced-hours programs than in the other programs (P < 0.05). Conclusion This study shows that it may be possible to reduce residents’ hours—and the perceived adverse impact of fatigue—while generally preserving the self-assessed quality, quantity, and outcomes of graduate medical education.

The role of cricopharyngeus muscle in pharyngoesophageal disorders

The cricopharyngeus muscle is generally thought to be responsible for the high pressure zone of the pharyngoesophageal (upper esophageal) sphincter. In this review we critically examined the evidence for the role of the cricopharyngeus muscle in the manometric pharyngoesophageal sphincter. The available studies show disparities between the anatomic location of the cricopharyngeus muscle and the manometric high pressure zone of the pharyngoesophageal sphincter. The cricopharyngeus muscle seems to correspond to the distal 1/3 of the sphineteric high pressure zone and the peak high pressure zone appears to be located proximal to the cricopharyngeus muscle. The discrepancy between the upper high pressure zone and the anatomic cricopharyngeus is important in understanding the role of the cricopharyngeus muscle in the pathophysiology and treatment of clinical disorders of the pharyngoesophageal sphincter.

Airway Obstruction and Sleep Apnea in Hurler and Hunter Syndromes

The Hurler and Hunter syndromes are two forms of mucopolysaccharidosis. Although the diseases are rare, those afflicted commonly require otolaryngologic consultation. Upper airway obstruction is often severe, progressive, and not infrequently the suspected cause of death in these patients. Four patients with these problems are presented. In all of the children, obstructive sleep apnea was a major management problem. This and other upper airway difficulties are detailed with clinical and pathological correlates.

Talking with Patients about Other Clinicians' Errors

The authors discuss the challenges facing a clinician who discovers that her patient has been harmed by another health care workers medical error. They provide guidance to help clinicians and institutions disclose such errors to patients.

The effect of bolus consistency on dysphagia in unilateral vocal cord paralysis

OBJECTIVE To examine the risk of aspiration for liquid versus paste bolus consistencies in patients with unilateral vocal cord paralysis (UVCP). METHODS The swallowing function of adult patients with UVCP was prospectively studied videofluorographically to examine the incidence of laryngeal penetration and aspiration for both liquid and paste boluses. The degree of penetration or aspiration was quantified using the penetration-aspiration scale (PAS). The presence and location of pharyngeal bolus residue were also documented for each consistency. Results were compared between liquid and paste bolus consistencies. RESULTS Fifty-five patients with UVCP were studied with a mean age of 60.2 years. Intrathoracic surgery or malignancy accounted for 38 (69.1%) of cases. The mean PAS scores for liquid and paste bolus consistency were 3.1 vs. 1.5, respectively (P < 0.001). The liquid bolus penetrated in 19 (34.5%) patients and was aspirated in 11 (20%) patients. In contrast, the paste bolus penetrated in 12 (21.8%) cases and was aspirated in 0 cases (P < 0.001). Pharyngeal residue was more likely to occur at the base of the tongue or vallecula for the paste bolus consistency versus the liquid bolus. CONCLUSIONS A significant percentage of patients with UVCP will aspirate thin liquids. Paste bolus consistencies are safer for patients with UVCP as they are much less likely to lead to penetration or aspiration despite a higher prevalence of pharyngeal residue.

Instituting a Culture of Professionalism: The Establishment of a Center for Professionalism and Peer Support

BACKGROUND There is growing recognition that an environment in which professionalism is not embraced, or where expectations of acceptable behaviors are not clear and enforced, can result in medical errors, adverse events, and unsafe work conditions. METHODS The Center for Professionalism and Peer Support (CPPS) was created in 2008 at Brigham and Womens Hospital (BWH), Boston, to educate the hospital community regarding professionalism and manage unprofessional behavior. CPPS includes the professionalism initiative, a disclosure and apology process, peer and defendant support programs, and wellness programs. Leadership support, establishing behavioral expectations and assessments, emphasizing communication engagement and skills training, and creating a process for intake of professionalism concerns were all critical in developing and implementing an effective professionalism program. The process for assessing and responding to concerns includes management of professionalism concerns, an assessment process, and remediation and monitoring. RESULTS Since 2005, thousands of physicians, scientists, nurse practitioners, and physician assistants have been trained in educational programs to support the identification, prevention, and management of unprofessional behavior. For January 1, 2010, through June 30, 2013, concerns were raised regarding 201 physicians/scientists and 8 health care teams. CONCLUSIONS The results suggest that mandatory education sessions on professional development are successful in engaging physicians and scientists in discussing and participating in an enhanced professionalism culture, and that the processes for responding to professionalism concerns have been able to address, and most often alter, repetitive unprofessional behavior in a substantive and beneficial manner.

Peer Support for Clinicians: A Programmatic Approach.

Burnout is plaguing the culture of medicine and is linked to several primary causes including long work hours, increasingly burdensome documentation, and resource constraints. Beyond these, additional emotional stressors for physicians are involvement in an adverse event, especially one that involves a medical error, and malpractice litigation. The authors argue that it is imperative that health care institutions devote resources to programs that support physician well-being and resilience. Doing so after adverse and other emotionally stressful events, such as the death of a colleague or caring for victims of a mass trauma, is crucial as clinicians are often at their most vulnerable during such times. To this end, the Center for Professionalism and Peer Support at Brigham and Womens Hospital redesigned the peer support program in 2009 to provide one-on-one peer support. The peer support program was one of the first of its kind; over 25 national and international programs have been modeled off of it. This Perspective describes the origin, structure, and basic workings of the peer support program, including important components for the peer support conversation (outreach call, invitation/opening, listening, reflecting, reframing, sense-making, coping, closing, and resources/referrals). The authors argue that creating a peer support program is one way forward, away from a culture of invulnerability, isolation, and shame and toward a culture that truly values a sense of shared organizational responsibility for clinician well-being and patient safety.