Katherine Margo

Medical Student Documentation in Electronic Health Records: A Collaborative Statement From the Alliance for Clinical Education

Purpose: The electronic health record (EHR) is an important advancement in health care. It facilitates improvement of health care delivery and coordination of care, but it creates special challenges for student education. This article represents a collaborative effort of the Alliance for Clinical Education (ACE), a multidisciplinary group formed in 1992. ACE recognizes the importance of medical student participation in patient care including the ability of documentation. This article proposes guidelines that can be used by educators to establish expectations on medical student documentation in EHRs. Summary: To provide the best education for medical students in the electronic era, ACE proposes to use the following as practice guidelines for medical student documentation in the EHR: (a) Students must document in the patients chart and their notes should be reviewed for content and format, (b) students must have the opportunity to practice order entry in an EHR—in actual or simulated patient cases—prior to graduation, (c) students should be exposed to the utilization of the decision aids that typically accompany EHRs, and (d) schools must develop a set of medical student competencies related to charting in the EHR and state how they would evaluate it. This should include specific competencies to be documented at each stage, and by time of graduation. In addition, ACE recommends that accreditation bodies such as the Liaison Committee for Medical Education utilize stronger language in their educational directives standards to ensure compliance with educational principles. This will guarantee that the necessary training and resources are available to ensure that medical students have the fundamental skills for lifelong clinical practice. Conclusions: ACE recommends that medical schools develop a clear set of competencies related to student in the EHR which medical students must achieve prior to graduation in order to ensure they are ready for clinical practice.

Opportunities and Challenges in Integrating Electronic Health Records Into Undergraduate Medical Education: A National Survey of Clerkship Directors

Background: Few studies have reported on the utilization and the effect of electronic health records on the education of medical students. Purpose: The purpose of this study was to describe the current use of electronic health records by medical students in the United States and explore the opportunities and challenges of integrating electronic health records into daily teaching of medical students. Methods: A survey with 24 questions regarding the use of electronic health records by medical students was developed by the Alliance for Clinical Educators and sent to clerkship directors across the United States. Both quantitative and qualitative responses were collected and analyzed to determine current access to and use of electronic health records by medical students. Results: This study found that an estimated 64% of programs currently allow student use of electronic health records, of which only two thirds allowed students to write notes within the electronic record. Overall, clerkship directors’ opinions on the effects of electronic health records on medical student education were neutral, and despite acknowledging many advantages to electronic health records, there were many concerns raised regarding their use in education. Conclusions: Medical students are using electronic health records at higher rates than physicians in practice. Although this is overall reassuring, educators have to be cautious about the limitations being placed on students documentation in electronic health records as this can potentially have consequences on their training, and they need to explore ways to maximize the benefits of electronic health records in medical education.

Patient Characteristics Associated with Participation in a Practice-Based Study of Depression in Late Life: The Spectrum Study

Objective: An important component of generalizing study results to patients is the extent to which study participants adequately represent individuals targeted for the study. The Spectrum study of depression in older primary care patients was utilized to consider patient characteristics associated with nonparticipation. Method: Interviewers utilized a validated questionnaire to screen adults aged 65 years and older for depression who presented to one of the participating primary care practices in the Baltimore, Maryland area. Screening interviews included information about sociodemographic factors, functioning, health, and attitudes about depression and its treatment in order to compare participants with persons who declined. Results: In all, 2,560 adults aged 65 years and older were screened. Comparison of the characteristics of the patients who were eligible for the study (n = 773) with patients who participated fully in the in-home evaluation (n = 355) found that the study sample included proportionately more persons who: 1) were less than 80 years old; 2) completed high school; and 3) reported two or more visits to the practice site within six months of the interview. Among patients who were depressed, no significant differences were found in the characteristics of those who met study eligibility criteria and those who agreed to participate. Conclusions: Persons over the age of 80 years of age or those with less than a high school education may require tailored strategies for recruitment even when approached by a trained interviewer in a primary care doctors office.

IMPROVING TRANSGENDER HEALTH EDUCATION FOR FUTURE DOCTORS

We wholeheartedly agree with the assertion, in Stroumsa’s excellent and comprehensive review of transgender health, that future physicians must be trained to meet the unique health needs of the more than one million gender-variant people in the United States. 1 To move toward this goal, the first step at our medical school was to understand student knowledge, attitudes, and skills related to transgender health and to assess the impact of an educational intervention. A new lecture on transgender health was given to medical students (n = 139) during their required family medicine clerkship. Upon finishing the clerkship year and prior to graduation, these students completed a 26-item survey assessing transgender health knowledge, attitudes, and skills. A similar survey was completed upon graduation by students in a more senior cohort who had not received the lecture during their clerkships (n = 145). Self-reported competency items were rated on a 5-point Likert scale, and summary scores were created if internal consistency estimates were adequate (Cronbach a >0 .7). The propensity score or probability that a participant would have attended the lecture was estimated using a multivariate logistic regression model incorporating demographic and attendance variables. The effect of the transgender health lecture on knowledge, attitudes, and skills was examined in a regression model adjusting for the propensity score. The survey response rate was 72%

Undergraduate Students’ Perspectives on Primary Care

Background and Objectives: Despite the need for more primary care physicians, the number of medical students choosing primary care careers remains lower than other specialties. While undergraduate premedical education is an essential component in the development of future physicians, little is known about undergraduate students’ perspectives on becoming primary care physicians. To better understand the early factors in career selection, we asked premed and former premed students their perceptions of primary care. Methods: Open-ended, semistructured interviews were conducted with 58 undergraduate students who represented three different groups: those who were currently premed and science majors, those who were nonscience majors and were currently premed, and those who were formerly premed. Specifically, we asked, “Why do you think there is a shortage of people who go into primary care?” Results: Undergraduates cited financial reasons, lack of “glamour,” and the career being “uninteresting.” Many believed that primary care lacked prestige, and others felt it had a negative stigma attached. Most had never even considered a career in primary care. A number of students also misunderstood what a career in primary care actually entailed. Conclusions: As early as freshman year in college, undergraduate students harbor misconceptions and negative opinions about primary care. Many of those who express interest in such a career seem to drop out of the premedical program. It is important to consider the early onset of these attitudes and a way to target this interested population when trying to address the shortage of primary care physicians.

A high- or low-dose triamcinolone injection improved pain and function in adhesive capsulitis

Source Citation Yoon SH, Lee HY, Lee HJ, Kwack KS. Optimal dose of intra-articular corticosteroids for adhesive capsulitis: a randomized, triple-blind, placebo-controlled trial. Am J Sports Med. 20...

Review: Corticosteroids improve short-term outcomes but worsen longer-term outcomes in some types of tendinopathy

Source Citation Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled...

Male body image and weight-related disorders.

zation in the VCD group. He suggests that an immobilization time of as short as 1 hour might be sufficient even after manual compression. We chose 6 hours for the pressure bandage after manual compression because this has been our institutional practice for more than 10 years prior to the study and is also used in many other centers. A shorter immobilization time might also be used as was done in the study referenced by Hoffer.1 However, in the latter study, in which the investigators used a 1-hour immobilization time for the manual compression group, use of VCDs significantly reduced the rate of local hematoma.1 Thus, the results of the ISAR-CLOSURE and the Closure Devices Used in Everyday Practice1 trials suggest that VCDs shorten immobilization time without increasing the risk of local complications if longer immobilization time for manual compression is practiced, or reduce the risk of local complications in centers in which manual compression is followed by only 1 hour of immobilization.

Review: some clinical tests performed by specialists identify rotator cuff disease or tears.

Question How accurate are clinical examinations for diagnosing rotator cuff disease (RCD)? Review scope Included studies compared clinical examination with diagnostic imaging (ultrasonography or magnetic resonance imaging) with prespecified diagnostic criteria and described history taking, physical examination, and clinical tests for RCD. Studies of shoulder disorders secondary to rheumatoid arthritis, fibromyalgia, shoulder instability, labral lesions, fractures, adhesive capsulitis, tumors, the complex regional pain syndrome, or disorders resulting from stroke were excluded. Outcomes included sensitivity, specificity, and likelihood ratios (LRs). Review methods MEDLINE, EMBASE/Excerpta Medica, and CINAHL (all to May 2013), and reference lists of included studies were searched for studies published in Danish, Dutch, English, French, German, Norwegian, Spanish, or Swedish, in which original data were presented or could be obtained from authors. 28 studies met the selection criteria. 5 studies (n =432, 442 shoulders, mean age range 44 to 58 y) had level 1 or 2 evidence based on the Quality Assessment of Diagnostic Accuracy Studies criteria and were included in meta-analyses. Main results All patients were referred to specialists for evaluation of shoulder discomfort. Prevalence of RCD ranged from 33% to 81%. The Table shows the diagnostic test characteristics of clinical tests with LRs for a positive test result (LRs+) >2.0 or for which 3 studies provided data. The Neer test, which was assessed in 2 studies, had 64% to 68% sensitivity, 30% to 61% specificity, LR+0.98 to 1.6, and likelihood ratio of a negative test (LR) 0.60 to 1.1. Conclusion In patients with shoulder discomfort, some clinical tests performed by specialists identify rotator cuff disease or tears. Test characteristics of clinical tests for diagnosing rotator cuff disease or tears* Tests Rotator cuff condition Sensitivity (95% CI) Specificity (CI) LR+ LR Painful arc Disease 71% (60 to 83) 81% (68 to 93) 3.7 0.36 Hawkins Disease 76% (56 to 89) 48% (23 to 74) 1.5 0.51 Drop arm Disease 24% (13 to 34) 93% (85 to 100) 3.3 0.82 External rotation resistance Disease 63% (49 to 77) 75% (69 to 82) 2.6 0.49 Full can Disease 75% (64 to 85) 68% (54 to 83) 2.4 0.37 Empty can (Jobe) Disease 71% (49 to 86) 49% (42 to 56) 1.3 0.64 External rotation lag Full tear 47% (21 to 71) 94% (85 to 100) 7.2 0.57 Internal rotation lag Full tear 97% (88 to 100) 83% (70 to 96) 5.6 0.04 Dropping sign Full tear 73% (51 to 95) 77% (62 to 92) 3.2 0.35 *Abbreviations defined in Glossary. The gold standard was diagnostic imaging (ultrasound and/or magnetic resonance imaging). Only tests with LR+ >2 or that were evaluated in 3 studies are presented. 3 studies provided data for the Hawkins and Empty can tests; 1 study provided data for each of the other tests. Commentary RCD is the most common cause of shoulder problems in the primary care setting; however, this disorder is challenging for primary care physicians to diagnose (1). The history is generally too nonspecific to make the diagnosis, although the most common symptoms are shoulder and arm pain, especially with overhead motions. Diagnosis by physical examination has been difficult given the low sensitivity and specificity of the many maneuvers available. The review by Hermans and colleagues shows that several tests are clearly superior in sensitivity and specificity for diagnosing RCD. There are 2 types of examination maneuverspain-provocation tests and strength tests. For the pain-provocation tests, the painful arc, rather than the usually touted Hawkins and Neer tests, has the most helpful characteristics, with an LR+ >2.0. Of the 5 strength tests evaluated, the external rotation lag test and internal rotation lag test were most accurate for diagnosing a full rotator cuff tear, with the latter having the best LR. Another recent systematic review (2) found that the Hawkins, Neer, and empty can tests were best for ruling out the subacromial impingement syndrome (which includes RCD and subacromial bursitis). The lift-off test (similar to the internal rotation lag test) had the highest LR+. None of the studies in either review were done in a primary care setting, meaning that the patient population studied is more likely to have significant disease. However, the tests, which are explained in detail in the articles, should be easy for primary care physicians to master and should help to guide management decisions. More office-based ultrasound capability will help to make diagnosis even more accurate than the imperfect physical examination tests we have.

Review: back exercise interventions prevent self-reported episodes of back problems in adults but ergonomic education does not

Which interventions prevent back problems in adults? Included studies evaluated any intervention for preventing episodes of back problems (back symptoms or limited activity because of back pain or sciatica) in people 18–65 years of age. Studies that reported changes in anatomy or physiology or knowledge outcomes, or evaluated patient treatment to reduce disability were excluded. Outcomes included self-reported back problems. Medline and EMBASE/Excerpta Medica (to May 2007), Cochrane Back Review Group Specialised Trial Registry (to Aug 2008), and reference lists were searched for randomised controlled trials (RCTs) or other controlled trials (OCTs). 17 high-quality RCTs and 3 OCTs met the selection criteria. Meta-analysis …