John M. Byrne

Initial Experience with Patient-Clinician Secure Messaging at a VA Medical Center

The authors implemented what is possibly the first secure messaging system in a VA Medical Center. Since reimbursement for secure messaging is not of great concern and clinical data systems are fully computerized, several evaluation strategies were used to assess clinical adoption. To address known concerns of clinicians, the authors analyzed secure messaging use and performed a content analysis. Message volumes were low and content analysis demonstrated that messages were appropriate. Despite this, a clinician survey showed that clinical adoption was impeded by several factors including the introduction of secure messaging to selected patients, workload concerns, and clinician communication preferences. In addition, the authors believe that clinicians experienced clinical adoption inertia resulting from the overload of information in a highly computerized clinical environment. The authors learned that to promote clinician adoption they must demonstrate workload benefits from secure messaging and more fully analyze the clinical computing workload that clinicians experience.

Factors Determining Medical Students’ and Residents’ Satisfaction During Va-based Training: Findings from the Va Learners’ Perceptions Survey

Purpose To compare medical students’ and physician residents’ satisfaction with Veterans Affairs (VA) training to determine the factors that were most strongly associated with trainee satisfaction ratings. Method Each year from 2001 to 2006, all medical students and residents in VA teaching facilities were invited to complete the Learners’ Perceptions Survey. Participants rated their overall training satisfaction on a 100-point scale and ranked specific satisfaction in four separate educational domains (learning environment, clinical faculty, working environment, and physical environment) on a five-point Likert scale. Each domain was composed of unique items. Results A total of 6,527 medical students and 16,583 physician residents responded to the survey. The overall training satisfaction scores for medical students and physician residents were 84 and 79, respectively (P < .001), with significant differences in satisfaction reported across the training continuum. For both medical students and residents, the rating of each of the four educational domains was statistically significantly associated with the overall training satisfaction score (P < .001). The learning environment domain had the strongest association with overall training satisfaction score, followed by the clinical preceptor, working environment, and physical environment domains; no significant differences were found between medical students and physician residents in the rank order. Satisfaction with quality of care and faculty teaching contributed significantly to training satisfaction. Conclusions Factors that influence training satisfaction were similar for residents and medical students. The domain with the highest association was the learning environment; quality of care was a key item within this domain.

Exercise-induced complete heart block in a patient with chronic bifascicular block

Heart block induced by exercise or associated with symptomatic, chronic bifascicular block can progress to high-grade atrioventricular (AV) block and sudden death. The authors describe a case of exercise-induced AV block in a patient with chronic bifascicular block. Thirty seconds of ventricular asystole were observed during exercise treadmill testing. Myocardial ischemia was ruled out, and the cause was determined to be distal AV nodal block. The pathophysiology, diagnosis, and treatment of distal AV nodal block are reviewed. The role of exercise treadmill testing and electrophysiologic studies in distal AV block are outlined in a diagnostic and therapeutic strategy.

Quality and Safety Training in Primary Care: Making an Impact

PURPOSE Preparing residents for future practice, knowledge, and skills in quality improvement and safety (QI/S) is a requisite element of graduate medical education. Despite many challenges, residency programs must consider new curricular innovations to meet the requirements. We report the effectiveness of a primary care QI/S curriculum and the role of the chief resident in quality and patient safety in facilitating it. METHOD Through the Veterans Administration Graduate Medical Education Enhancement Program, we added a position for a chief resident in quality and patient safety, and 4 full-time equivalent internal medicine residents, to develop the Primary Care Interprofessional Patient-Centered Quality Care Training Curriculum. The curriculum includes a first-or second-year, 1-month block rotation that serves as a foundational experience in QI/S and interprofessional care. The responsibilities of the chief resident in quality and patient safety included organizing and teaching the QI/S curriculum and mentoring resident projects. Evaluation included prerotation and postrotation surveys of self-assessed QI/S knowledge, abilities, skills, beliefs, and commitment (KASBC); an end-of-the-year KASBC; prerotation and postrotation knowledge test; and postrotation and faculty surveys. RESULTS Comparisons of prerotation and postrotation KASBC indicated significant self-assessed improvements in 4 of 5 KASBC domains: knowledge (P < .001), ability (P < .001), skills (P < .001), and belief (P < .03), which were sustained on the end-of-the-year survey. The knowledge test demonstrated increased QI/S knowledge (P  =  .002). Results of the postrotation survey indicate strong satisfaction with the curriculum, with 76% (25 of 33) and 70% (23 of 33) of the residents rating the quality and safety curricula as always or usually educational. Most faculty members acknowledged that the chief resident in quality and patient safety enhanced both faculty and resident QI/S interest and participation in projects. CONCLUSIONS Our primary care QI/S curriculum was associated with improved and persistent resident self-perceived knowledge, abilities, and skills and increased knowledge-based scores of QI/S. The chief resident in quality and patient safety played an important role in overseeing the curriculum, teaching, and providing leadership.

Evidence-Based Medicine and the Search for a Science of Clinical Care

Daly J. 290 pages. Berkeley, CA: Univ California Pr; 2005.

Studying the effects of ACGME duty hours limits on resident satisfaction: results from VA learners' perceptions survey.

65.00. ISBN 0520243161. Order at www.ucpress.edu. Field of medicine: Evidence-based medicine and clinical epidemiology. Format: Hardcover book. Audience: Teachers, students, and evidence-based medicine practitioners. Purpose: To provide a comprehensive history of the origins and development of evidence-based medicine and its permeation into clinical practice. Content: The author details the emergence of evidence-based medicine as a scientific method for clinical decision making and traces the intellectual contributions of its leaders. She articulates the rationale for evidence-based medicine but also challenges its tenets by enumerating the history and work of its many detractors. The author discusses the ascendance of the randomized, controlled trial and the elevation of meta-analyses as the preeminent science of clinical care, along with the limitations of applying clinical trial data to complex patient care decisions. The book challenges evidence-based medicines focus, direction, and reach in clinical care, patient participation, research, medical economics, and public policy. Highlights: The authors interviews with the central figures of evidence-based medicine provide an intimate view of its development and insights into the creativity and vision of its leaders. The author provides an insightful critique of the discipline, including an analysis of personal relevance, her exploration of the dissemination of evidence-based medicine in her home country of South Africa. She describes a medical education system reliant on authority as the construct for teaching clinical decision making and a culture in which politics subvert evidence, highlighting the global challenges facing evidence-based medicines proponents and public policymakers. For practicing physicians, the book provides a balanced perspective of evidence-based medicines role in patient care. Far from confirming a new paradigm for medical decision making, the author acknowledges the strengths and achievements of evidence-based medicine but sets an agenda for the continuing refinement and search for the science of clinical care. Limitations: Some of the individual histories are quite long and, in some instances, are repeated in other chapters. Related readings: Goodmans Ethics and Evidence-Based Medicine: Fallibility and Responsibility in Clinical Science (Cambridge Univ Pr, 2003) also reviews the history of evidence-based medicine and its related ethical dilemmas. Evidence-Based Practice: A Critical Approach (Blackwell Science, 2000), edited by Trinder with Reynolds, critically reviews evidence-based practice with consideration of alternative approaches. Reviewer: John M. Byrne, DO, Loma Linda University, School of Medicine, VA Loma Linda Healthcare System (14A), 11201 Benton Street, Loma Linda, California.