Mark J. Fagan

Satisfaction with Methods of Spanish Interpretation in an Ambulatory Care Clinic

AbstractOBJECTIVE: To describe the utilization of various methods of language interpretation by Spanish-speaking patients in an academic medical clinic and to determine patients’ and physicians’ satisfaction with these methods. METHODS: Survey administered to medical residents and Spanish-speaking patients asking about their experience and satisfaction with various methods of language interpretation. MAIN RESULTS: Both patients and residents had the highest level of satisfaction for professional interpreters (92.4% vs 96.1% reporting somewhat or very satisfactory, p=.17). In contrast, patients were significantly more satisfied than residents with using family members and friends (85.1% vs 60.8%, p<.01). Physicians and patients agreed that accuracy, accessibility, and respect for confidentiality were highly important characteristics of interpreters (>90% of both groups reporting somewhat or very important). However, patients were more concerned than residents about the ability of the interpreter to assist them after the physician visit (94% vs 45.1%, p<0.01). CONCLUSIONS: Using family members and friends as interpreters for Spanish-speaking patients should be more seriously considered; however, in order to optimize patient satisfaction, differences between patients and providers should be taken into account when using interpretation in medical settings.

Impact of Interpretation Method on Clinic Visit Length

AbstractOBJECTIVE: To determine the impact of interpretation method on outpatient visit length. DESIGN: Time-motion study. SETTING: Hospital-based outpatient teaching clinic. PARTICIPANTS: Patients presenting for scheduled outpatient visits. MEASUREMENTS AND MAIN RESULTS: Over a 6-week study period, a research assistant recorded the following information for consecutive patient visits: patient age, gender and insurance type; type of interpreter used (none, hospital interpreter, telephone interpreter or patient-supplied interpreter); scheduled visit length; provider type (nurse practitioner; attending physician; resident in postgraduate year 1, 2 or 3, or medical student); provider gender; amount of time the patient spent in the examination room with the provider (provider time); and total time the patient spent in the clinic from check-in to checkout (clinic time). When compared to patients not requiring an interpreter, patients using some form of interpreter had longer mean provider times (32.4 minutes [min] vs 28.0 min, P<.001) and clinic times (93.6 min vs 82.4 min, P=.002). Compared to patients not requiring an interpreter, patients using a telephone interpreter had significantly longer mean provider times (36.3 min vs 28.0 min, P < .001) and clinic times (99.9 min vs 82.4 min, P=.02). Similarly, patients using a patient-supplied interpreter had longer mean provider times (34.4 min vs 28.0 min, P<.001) and mean clinic times (92.8 min vs 82.4 min, P=.027). In contrast, patients using a hospital interpreter did not have significantly different mean provider times (26.8 min vs 28.0 min, P=.51) or mean clinic times (91.0 min vs 82.4 min, P=.16) than patients not requiring an interpreter. CONCLUSION: In our setting, telephone and patient-supplied interpreters were associated with longer visit times, but full-time hospital interpreters were not.

Self-Confidence in and Perceived Utility of the Physical Examination: A Comparison of Medical Students, Residents, and Faculty Internists

BACKGROUND AND OBJECTIVESLittle is known about the differences in attitudes of medical students, Internal Medicine residents, and faculty Internists toward the physical examination. We sought to investigate these groups’ self-confidence in and perceived utility of physical examination skills.DESIGN AND PARTICIPANTSCross-sectional survey of third- and fourth-year medical students, Internal Medicine residents, and faculty Internists at an academic teaching hospital.MEASUREMENTSUsing a 5-point Likert-type scale, respondents indicated their self-confidence in overall physical examination skill, as well as their ability to perform 14 individual skills, and how useful they felt the overall physical examination, and each skill, to be for yielding clinically important information.RESULTSThe response rate was 80% (302/376). The skills with overall mean self-confidence ratings less than “neutral” were interpreting a diastolic murmur (2.9), detecting a thyroid nodule (2.8), and the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature (2.5). No skills had a mean utility rating less than neutral. The skills with the greatest numerical differences between mean self-confidence and perceived utility were distinguishing between a mole and melanoma (1.5), detecting a thyroid nodule (1.4), and interpreting a diastolic murmur (1.3). Regarding overall self-confidence, third-year students’ ratings (3.3) were similar to those of first-year residents (3.4; p = .95) but less than those of fourth-year students (3.8; p = .002), upper-level residents (3.7; p = .01), and faculty Internists (3.9; p < .001).CONCLUSIONSSelf-confidence in the physical exam does not necessarily increase at each stage of training. The differences found between self-confidence and perceived utility for a number of skills suggest important areas for educational interventions.

Medical Students' Perspectives on and Responses to Abuse During the Internal Medicine Clerkship

Background: The abuse of medical students on clinical rotations is a recognized problem, but the effects on students and their responses warrant further study. Purpose: To determine the severity of student abuse and the effects of abuse on students during the internal medicine clerkship. Methods: Internal medicine clerks at 11 medical schools (N = 1,072) completed an exit survey. Students were asked whether they had been abused. If they had, they were asked about the severity of the abuse, whether they reported it, and its effects on them. Results: Of the responding students, 123 (11%) believed they had been abused. Only 31% of the students who felt abused reported the episodes to someone. The most common consequences of the events included poor learning environments, lack of confidence, and feelings of depression, anger, and humiliation. Conclusion: Students described a variety of personal and educational effects of abuse. They generally did not report abuse because of fear of retaliation and the belief that reporting is pointless.

Identifying and overcoming the barriers to bedside rounds: a multicenter qualitative study.

Purpose The use of bedside rounds in teaching hospitals has declined, despite recommendations from educational leaders to promote this effective teaching strategy. The authors sought to identify reasons for the decrease in bedside rounds, actual barriers to bedside rounds, methods to overcome trainee apprehensions, and proposed strategies to educate faculty. Method A qualitative inductive thematic analysis using transcripts from audio-recorded, semistructured telephone interviews with a purposive sampling of 34 inpatient attending physicians from 10 academic U.S. institutions who met specific inclusion criteria for “bedside rounds” was performed in 2010. Main outcomes were themes pertaining to barriers, methods to overcome trainee apprehensions, and strategies to educate faculty. Quotations highlighting themes are reported. Results Half of respondents (50%) were associate or full professors, averaging 14 years in academic medicine. Primary reasons for the perceived decline in bedside rounds were physician- and systems related, although actual barriers encountered related to systems, time, and physician-specific issues. To address resident apprehensions, six themes were identified: build partnerships, create safe learning environments, overcome with experience, make bedside rounds educationally worthwhile, respect trainee time, and highlight positive impact on patient care. Potential strategies for educating faculty were identified, most commonly faculty development initiatives, divisional/departmental culture change, and one-on-one shadowing opportunities. Conclusions Bedside teachers encountered primarily systems- and time-related barriers and overcame resident apprehensions by creating a learner-oriented environment. Strategies used by experienced bedside teachers can be used for faculty development aimed at promoting bedside rounds.

Do Attending Physicians, Nurses, Residents, and Medical Students Agree on What Constitutes Medical Student Abuse?

Background Whether attending physicians, residents, nurses, and medical students agree on what constitutes medical student abuse, its severity, or influencing factors is unknown. Method We surveyed 237 internal medicine attending physicians, residents, medical students, and nurses at 13 medical schools after viewing five vignettes depicting potentially abusive behaviors. Results The majority of each group felt the belittlement, ethnic insensitivity, and sexual harassment scenarios represented abuse but that excluding a student from participating in a procedure did not. Only a majority of attending physicians considered the negative feedback scenario as abuse. Medical students rated abuse severity significantly lower than other groups in the belittlement scenario (p < .05). Respondents who felt abused as students were more likely to rate behaviors as abusive (p < .05). Conclusions The groups generally agree on what constitutes abuse, but attending physicians and those abused as students may perceive more behaviors as abusive.

The prevalence and nature of postinterview communications between residency programs and applicants during the match.

Purpose To examine the frequency and nature of postinterview communications between programs and applicants during the National Resident Matching Program (NRMP) Main Residency Match. Method The authors surveyed senior medical students at seven U.S. medical schools about postinterview communications with residency programs during the 2010 Match and analyzed the data. Results The response rate was 68.2% (564/827). Among respondents, 86.4% reported communicating with residency programs. Most (59.9%) reported telling more than one program they would rank it highly; 1.1% reported telling more than one they would rank it first. Students reported that programs told them they would be “ranked to match” (34.6%), be “ranked highly” (52.8%), or “fit well” (76.2%). Almost one-fifth (18.6 %) reported feeling assured by a program that they would match there but did not despite ranking that program first; 23.4% reported altering their rank order list based on communications with programs. In multivariate analysis, applicants to more competitive specialties were less likely to report being told they would be “ranked to match” (relative risk [RR] 0.72, 95% confidence interval [CI] 0.52–0.99). Applicants were more likely to report being told that they would be “ranked to match” if they received honors in the specialty clerkship (RR 1.39, 95% CI 1.10–1.77) or were members of Alpha Omega Alpha (RR 1.72, 95% CI 1.37–2.17). Conclusions Reports of nonbinding communications with programs were frequent. Students should be advised to interpret any comments made by programs cautiously. Reported violations of the NRMP’s Match Participation Agreement were uncommon.

The Value of Bedside Rounds: A Multicenter Qualitative Study

Background: Bedside rounds have decreased on teaching services, raising concern about trainees’ clinical skills and patient–physician relationships. Purpose: We sought to identify recognized bedside teachers’ perceived value of bedside rounds to assist in the promotion of bedside rounds on teaching services. Methods: Authors used a grounded theory, qualitative study design of telephone semistructured interviews with bedside teachers (n = 34) from 10 U.S. institutions (2010–2011). Main outcomes were characteristics of participants, themes pertaining to the perceived value of bedside rounds, and quotations highlighting each respective theme. Results: The mean years in academic medicine was 13.7, and 51% were associate or full professors. Six main themes emerged: (a) skill development for learners (e.g., physical examination, communication, and clinical decision-making skills); (b) observation and feedback; (c) role-modeling; (d) team building among trainees, attending, and patient; (e) improved patient care delivery through combined clinical decision-making and team consensus; and (f) the culture of medicine as patient-centered care, which was embodied in all themes. Conclusions: Bedside teachers identify potential benefits of bedside rounds, many of which align with national calls to change our approach to medical education. The practice of bedside rounds enables activities essential to high-quality patient care and education.

Improving the Physical Diagnosis Skills of Third-year Medical Students: A Controlled Trial of a Literature-based Curriculum

AbstractOBJECTIVE: To determine if a literature-based physical diagnosis curriculum could improve student knowledge, skill, and self-confidence in physical diagnosis. DESIGN: Prospective controlled trial of an educational intervention. SETTING: Required internal medicine clerkship for third-year medical students at Brown Medical School. PARTICIPANTS: Third-year medical students who completed the internal medicine clerkship during the academic year 1999–2000: 32 students at 1 clerkship site received the intervention; a total of 50 students at 3 other clerkship sites served as controls. INTERVENTION: Physical diagnosis curriculum based on 8 articles from the Journal of the American Medical Association’s Rational Clinical Examination series. Intervention students met weekly for 1 hour with a preceptor to review each article, discuss the sensitivity and specificity of the maneuvers and findings, and practice the techniques with an inpatient who agreed to be visited and examined. MEASUREMENTS AND MAIN RESULTS: Physical diagnosis knowledge for the 8 topics was evaluated using a 22-item multiple choice question quiz, skill was evaluated using trained evaluators, and self-confidence was assessed using an end-of-clerkship survey. Intervention students scored significantly higher than the control group on the knowledge quiz (mean correct score 70% vs 63%, P=.002), skills assessment (mean correct score 90% vs 54%, P<.001), and self-confidence score (mean total score 40 vs 35, P=.003), and they expressed greater satisfaction with the physical diagnosis teaching they received in the clerkship. CONCLUSION: This physical diagnosis curriculum was successful in improving students’ knowledge, skill, and self-confidence in physical diagnosis.

Tobacco Cessation Among Low-Income Smokers: Motivational Enhancement and Nicotine Patch Treatment

INTRODUCTION Despite decades of tobacco use decline among the general population in the United States, tobacco use among low-income populations continues to be a major public health concern. Smoking rates are higher among individuals with less than a high school education, those with no health insurance, and among individuals living below the federal poverty level. Despite these disparities, smoking cessation treatments for low-income populations have not been extensively tested. In the current study, the efficacy of 2 adjunctive smoking cessation interventions was evaluated among low-income smokers who were seen in a primary care setting. METHODS A total of 846 participants were randomly assigned either to motivational enhancement treatment plus brief physician advice and 8 weeks of nicotine replacement therapy (NRT) or to standard care, which consisted of brief physician advice and 8 weeks of NRT. Tobacco smoking abstinence was at 1, 2, 6, and 12 months following baseline. RESULTS The use of the nicotine patch, telephone counseling, and positive decisional balance were predictive of increased abstinence rates, and elevated stress levels and temptation to smoke in both social/habit and negative affect situations decreased abstinence rates across time. Analyses showed intervention effects on smoking temptations, length of patch use, and number of telephone contacts. Direct intervention effects on abstinence rates were not significant, after adjusting for model predictors and selection bias due to perirandomization attrition. CONCLUSIONS Integrating therapeutic approaches that promote use of and adherence to medications for quitting smoking and that target stress management and reducing negative affect may enhance smoking cessation among low-income smokers.