Margaret Plews-Ogan

BRIEF REPORT: A Pilot Study Evaluating Mindfulness‐Based Stress Reduction and Massage for the Management of Chronic Pain

BACKGROUND: Mindfulness-based stress reduction (MBSR) and massage may be useful adjunctive therapies for chronic musculoskeletal pain.OBJECTIVE: To evaluate the feasibility of studying MBSR and massage for the management of chronic pain and estimate their effects on pain and mood.DESIGN: Randomized trial comparing MBSR or massage with standard care.PARTICIPANTS: Thirty patients with chronic musculoskeletal pain.MEASUREMENTS: Pain was assessed with 0 to 10 numeric rating scales. Physical and mental health status was measured with the SF-12.RESULTS: The study completion rate was 76.7%. At week 8, the massage group had average difference scores for pain unpleasantness of 2.9 and mental health status of 13.6 compared with 0.13 (P<.05) and 3.9 (P<.04), respectively, for the standard care group. These differences were no longer significant at week 12. There were no significant differences in the pain outcomes for the MBSR group. At week 12, the mean change in mental health status for the MBSR group was 10.2 compared with — 1.7 in the standard care group (P<.04).CONCLUSIONS: It is feasible to study MBSR and massage in patients with chronic musculoskeletal pain. Mindfulness-based stress reduction may be more effective and longer-lasting for mood improvement while massage may be more effective for reducing pain.

Patient safety in the ambulatory setting: A clinician-based approach

BACKGROUND: Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis.OBJECTIVES: To determine the feasibility and effectiveness of clinician-based near miss/adverse event voluntary reporting coupled with systems analysis and redesign as a model for continuous quality improvement in the ambulatory setting.DESIGN: We report the initial 1-year experience of voluntary reporting by clinicians in the ambulatory setting, coupled with root cause analysis and system redesign by a patient safety committee made up of clinicians from the practice.SETTING: Internal medicine practice site of a large teaching hospital with 25,000 visits per year.MEASUREMENTS AND MAIN RESULTS: There were 100 reports in the 1-year period, increased from 5 in the previous year. Faculty physicians reported 44% of the events versus 22% by residents, 31% by nurses, and 3% by managers. Eighty-three percent were near misses and 17% were adverse events. Errors involved medication (47%), lab or x-rays (22%), office administration (21%), and communication (10%) processes. Seventy-two interventions were recommended with 75% implemented during the study period.CONCLUSION: This model of clinician-based voluntary reporting, systems analysis, and redesign was effective in increasing error reporting, particularly among physicians, and in promoting system changes to improve care and prevent errors. This process can be a powerful tool for incorporating error reporting and analysis into the culture of medicine.

Wisdom in Medicine: What Helps Physicians After a Medical Error?

Purpose Confronting medical error openly is critical to organizational learning, but less is known about what helps individual clinicians learn and adapt positively after making a harmful mistake. Understanding what factors help doctors gain wisdom can inform educational and peer support programs, and may facilitate the development of specific tools to assist doctors after harmful errors occur. Method Using “posttraumatic growth” as a model, the authors conducted semistructured interviews (2009–2011) with 61 physicians who had made a serious medical error. Interviews were recorded, professionally transcribed, and coded by two study team members (kappa 0.8) using principles of grounded theory and NVivo software. Coders also scored interviewees as wisdom exemplars or nonexemplars based on Ardelt’s three-dimensional wisdom model. Results Of the 61 physicians interviewed, 33 (54%) were male, and on average, eight years had elapsed since the error. Wisdom exemplars were more likely to report disclosing the error to the patient/family (69%) than nonexemplars (38%); P < .03. Fewer than 10% of all participants reported receiving disclosure training. Investigators identified eight themes reflecting what helped physician wisdom exemplars cope positively: talking about it, disclosure and apology, forgiveness, a moral context, dealing with imperfection, learning/becoming an expert, preventing recurrences/improving teamwork, and helping others/teaching. Conclusions The path forged by doctors who coped well with medical error highlights specific ways to help clinicians move through this difficult experience so that they avoid devastating professional outcomes and have the best chance of not just recovery but positive growth.

The End of the 15–20 Minute Primary Care Visit

Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA; HarvardMedical School, Boston,MA, USA; Virginia Commonwealth University, Richmond, VA, USA; University of Virginia, Charlottesville, VA, USA; Louis Stokes Cleveland VAMC, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA; New York University School of Medicine, New York, NY, USA.

Achieving Transformational Change: Using Appreciative Inquiry for Strategic Planning in a School of Nursing

To achieve transformational change, a transformational approach is needed. The Appreciative Inquiry (AI) summit is a method that has been used to achieve transformational change in business for at least 20 years, but this innovative alternative approach is unknown to nursing. At the University of Virginia School of Nursing, an AI Summit was designed to bring all staff, faculty, student representatives, and members of the community together to rewrite the schools strategic plan. New connections within the school, the university, and the community were made when 135 participants engaged in the appreciative, 4-step AI process of discovering, dreaming, designing, and creating the schools future. During the summit, 7 strategic teams formed to move the school toward the best possible future while building on the existing positive core. This article describes 10 steps needed to design an AI summit and implications for using this method at other schools of nursing.

Addressing the Nation’s Physician Workforce Needs: The Society of General Internal Medicine (SGIM) Recommendations on Graduate Medical Education Reform

ABSTRACTThe Graduate Medical Education (GME) system in the United States (US) has garnered worldwide respect, graduating over 25,000 new physicians from over 8,000 residency and fellowship programs annually. GME is the portal of entry to medical practice and licensure in the US, and the pathway through which resident physicians develop the competence to practice independently and further develop their career plans. The number and specialty distribution of available GME positions shapes the overall composition of our national workforce; however, GME is failing to provide appropriate programs that support the delivery of our society’s system of healthcare. This paper, prepared by the Health Policy Education Subcommittee of the Society of General Internal Medicine (SGIM) and unanimously endorsed by SGIM’s Council, outlines a set of recommendations on how to reform the GME system to best prepare a physician workforce that can provide high quality, high value, population-based, and patient-centered health care, aligned with the dynamic needs of our nation’s healthcare delivery system. These recommendations include: accurate workforce needs assessment, broadened GME funding sources, increased transparency of the use of GME dollars, and implementation of incentives to increase the accountability of GME-funded programs for the preparation and specialty selection of their program graduates.

Stories of Growth and Wisdom: A Mixed-Methods Study of People Living Well With Pain.

Chronic pain remains a daunting clinical challenge, affecting 30% of people in the United States and 20% of the global population. People meeting this challenge by achieving wellbeing while living with pain are a virtually untapped source of wisdom about this persistent problem. Employing a concurrent mixed-methods design, we studied 80 people living with chronic pain with “positive stories to tell” using semi-structured interviews and standardized questionnaires. In-depth interviews focused on what helped, what hindered, how they changed, and advice for others in similar circumstances. Major qualitative themes included acceptance, openness, self-efficacy, hope, perseverance, self-regulation, kinesthetic awareness, holistic approaches and integrative therapies, self-care, spirituality, social support, and therapeutic lifestyle behaviors such as music, writing, art, gardening, and spending time in nature. Themes of growth and wisdom included enhanced relationships, perspective, clarity, strength, gratitude, compassion, new directions, and spiritual change. Based on narrative analysis of the interviews and Ardelts Three-Dimensional Wisdom Model, participants were divided into 2 groups: 59 wisdom exemplars and 21 nonexemplars. Non-exemplar themes were largely negative and in direct contrast to the exemplar themes. Quantitatively, wisdom exemplars scored significantly higher in Openness and Agreeableness and lower in Neuroticism compared to non-exemplars. Wisdom exemplars also scored higher in Wisdom, Gratitude, Forgiveness, and Posttraumatic Growth than non-exemplars, and more exemplars used integrative therapies compared to the non-exemplars. As a whole, the exemplar narratives illustrate a Positive Approach Model (PAM) for living well with pain, which allows for a more expansive pain narrative, provides positive role models for patients and clinicians, and contributes to a broader theoretical perspective on persistent pain.

A randomized controlled trial evaluating Mindfulness-Based Stress Reduction (MBSR) for the treatment of palpitations: A pilot study.

Article history: Received 26 July 2016 Accepted 8 August 2016 Available online 9 August 2016 heart palpitations is associated with improved autonomic balance during 24 h Holter recordings. We conducted a randomized trial of an 8 week MBSR class compared to a wait-list control group in patients with palpitations, in a protocol approved by the UVA IRB. Twenty participations reporting heart palpitations of at least two months duration were recruited in the UVA Primary Care and Cardiology

Comparison of patient data in parallel records: The sign-out sheet and the electronic medical record

Electronic medical record and separate sign-out system data (code status, location, medications and laboratory results) from 60 patients were compared to assess the impact of parallel data systems. In addition, a survey was administered to 74 Internal Medicine residents to characterize what elements they self-report using in their sign-out system. The survey results indicated that residents use the separate sign-out system to support hand-off of care, but also patient care. The data comparison showed that while code status data matched for all patients, 28.3% of patients had a location entered into the sign-out system that did not match the medical record. 46 (76.7%) patients had a medication reported in the sign-out report that did not match the medical record. Of 180 laboratory values compared, 130 (72%) matched the most recent value or a value within the past 24 hours. Using a criterion of “medically relevant matches”, a test of proportion indicated that significantly more laboratory values agree, thus supporting the hypothesis that physicians are less likely to update data when changes are not medically relevant. To reduce workload and the amount of inaccurate information being passed to physicians, sign-out functionality should be integrated into electronic medical record systems.

Information, Data Entry, and Reporting Requirements for a Resident Handoff of Care Support Tool

Physician handoff of care is a mechanism for transferring patient information, responsibility, and authority from one set of caregivers to another. At shift change at a hospital, residents going off shift handoff patients to those coming on shift. There are limited handoff of care tools that facilitate the handover process by condensing patient information in reports that can be referenced during the handoff of care and used during patient care as cognitive artifacts. This effort works to address information, data entry and reporting requirements for a resident handoff of care tool that would support transfer of information as well as patient care.