Reva Kleppel

Phantom vibration syndrome among medical staff: a cross sectional survey

Objective To describe the prevalence of and risk factors for experiencing “phantom vibrations,” the sensory hallucination sometimes experienced by people carrying pagers or cell phones when the device is not vibrating. Design Cross sectional survey. Setting Academic medical centre. Participants 176 medical staff who responded to questionnaire (76% of the 232 people invited). Measurements Electronic survey consisting of 17 questions about demographics, device use, phantom vibrations experienced, and attempts to stop them. Results Of the 169 participants who answered the question, 115 (68%, 95% confidence interval 61% to 75%) reported having experienced phantom vibrations. Most (68/112) who experienced phantom vibrations did so after carrying the device between 1 month and 1 year, and 13% experienced them daily. Four factors were independently associated with phantom vibrations: occupation (resident v attending physician, prevalence ratio 1.47, 95% confidence interval 1.10 to 1.97), device location (breast pocket v belt, prevalence ratio 1.66, 1.29 to 2.14), hours carried (per 6 hour increment, prevalence ratio 1.30, 1.07 to 1.58), and more frequent use in vibrate mode (per frequency category, prevalence ratio 1.18, 1.03 to 1.34). Of those who experienced phantom vibrations, 43 (39%, 30% to 48%) were able to stop them. Strategies for stopping phantom vibrations included taking the device off vibrate mode, changing the location of the device, and using a different device (success rates 75% v 63% v 50%, respectively, P=0.217). However, 39% (30% to 49%) of respondents did not attempt any strategies. Conclusions Phantom vibration syndrome is common among those who use electronic devices.

Implementing a resident research program to overcome barriers to resident research.

Internal medicine residents are required to participate in scholarly activity, but conducting original research during residency is challenging. Following a poor Match at Baystate Medical Center, the authors implemented a resident research program to overcome known barriers to resident research. The multifaceted program addressed the following barriers: lack of interest, lack of time, insufficient technical support, and paucity of mentors. The program consisted of evidence-based medicine training to stimulate residents’ interest in research and structural changes to support their conduct of research, including protected time for research during ambulatory blocks, a research assistant to help with tasks such as institutional review board applications and data entry, a research nurse to help with data collection, easily accessible biostatistical support, and a resident research director to provide mentorship. Following implementation in the fall of 2005, there was a steady rise in the number of resident presentations at national meetings, then in the number of resident publications. From 2001 to 2006, the department saw 3 resident publications. From 2006 to 2012, that number increased to 39 (P< .001). The department also saw more original research (29 publications) and resident first authors (12 publications) after program implementation. The percentage of residents accepted into fellowships rose from 33% before program implementation to 49% after (P = .04). This comprehensive resident research program, which focused on evidence-based medicine and was tailored to overcome specific barriers, led to a significant increase in the number of resident Medline publications and improved the reputation of the residency program.

Getting doctors to clean their hands: lead the followers

Background Despite ample evidence that hand hygiene (HH) can reduce nosocomial infections, physician compliance remains low. The authors hypothesised that attending physician role modelling and peer pressure among internal medicine teams would impact HH adherence. Methods Nine teams were covertly observed. Team member entry and exit order, and adherence to HH were recorded secretly. The mean HH percentage across encounters was estimated by compliance of the first person entering and exiting an encounter, and by the attending physicians HH compliance. Results 718 HH opportunities prior to contact and 744 opportunities after contact were observed. If the first person entering a patient encounter performed HH, the mean compliance of other team members was 64%, but was only 45% if the first person failed to perform HH (p=0.002). When the attending physician performed HH upon entering the patient encounter, the mean HH compliance was 66%, but only 42% if the attending physician did not perform HH (p<0.001). Similar results were seen on exiting the room. The effects of the first person were not driven solely by the attending physicians HH behaviour because the attending physician was first or second to enter 57% of the encounters and exit 44% of the encounters. Conclusions If the first person entering a patient room performs HH, then others were more likely to perform HH too, implying that peer pressure impacts team member HH compliance. The attending physicians behaviour also influenced team members regardless of whether the attending physician was the first to enter or exit an encounter, implying that role modelling impacts the HH behaviour of learners. These findings should be used when designing HH improvement programmes targeting physicians.

The cost of defensive medicine on 3 hospital medicine services.

The overuse of tests and procedures due to fear of malpractice litigation, known as defensive medicine,1 is estimated to cost

Informed Decision Making for Percutaneous Coronary Intervention for Stable Coronary Disease

46 billion annually in the US,2 but these costs have been measured only indirectly. We estimated the cost of defensive medicine on three hospital medicine services in a health system by having physicians assess the defensiveness of their own orders. We hypothesized that physicians who were concerned about being targeted by litigation would practice more defensively and have higher overall costs.

Hospital workers’ perceptions of waste: a qualitative study involving photo-elicitation

IMPORTANCE Patients with stable coronary disease undergoing percutaneous coronary intervention (PCI) are frequently misinformed about the benefits of PCI. Little is known about the quality of decision making before angiography and possible PCI. OBJECTIVE To assess the quality of informed decision making and its association with patient decisions. DESIGN, SETTING, AND PARTICIPANTS We performed a cross-sectional analysis of recorded conversations between August 1, 2008, and August 31, 2012, among adults with known or suspected stable coronary disease at outpatient cardiology practices. MAIN OUTCOMES AND MEASURES Presence of 7 elements of informed decision making and the decision to undergo angiography and possible PCI. RESULTS Of 59 conversations conducted by 23 cardiologists, 2 (3%) included all 7 elements of informed decision making; 8 (14%) met a more limited definition of procedure, alternatives, and risks. Specific elements significantly associated with not choosing angiography and possible PCI included discussion of uncertainty (odds ratio [OR], 20.5; 95% CI, 2.3-204.9), patients role (OR, 5.3; 95% CI, 1.3-21.3), exploration of alternatives (OR, 9.5; 95% CI, 2.5-36.5), and exploration of patient preference (OR, 4.8; 95% CI, 1.2-19.4). Neither the presence of angina nor severity of symptoms was associated with choosing angiography and possible PCI. In a multivariable analysis using the total number of elements as a predictor, better informed patients were less likely to choose angiography and possible PCI (OR per additional element, 3.2; 95% CI, 1.4-7.1; P = .005). CONCLUSIONS AND RELEVANCE In conversations between cardiologists and patients with stable angina, informed decision making is often incomplete. More complete discussions are associated with patients choosing not to undergo angiography and possible PCI.

Procedural sedation for MRI in children with ADHD

Objectives To elicit sources of waste as viewed by hospital workers. Design Qualitative study using photo-elicitation, an ethnographic technique for prompting in-depth discussion. Setting U.S. academic tertiary care hospital. Participants Physicians, nurses, pharmacists, administrative support personnel, administrators and respiratory therapists. Methods A purposive sample of personnel at an academic tertiary care hospital was invited to take up to 10 photos of waste. Participants discussed their selections using photos as prompts during in-depth interviews. Transcripts were analysed in an iterative process using grounded theory; open and axial coding was performed, followed by selective and thematic coding to develop major themes and subthemes. Results Twenty-one participants (nine women, average number of years in field=19.3) took 159 photos. Major themes included types of waste and recommendations to reduce waste. Types of waste comprised four major categories: Time, Materials, Energy and Talent. Participants emphasised time wastage (50% of photos) over other types of waste such as excess utilisation (2.5%). Energy and Talent were novel categories of waste. Recommendations to reduce waste included interventions at the micro-level (eg, individual/ward), meso-level (eg, institution) and macro-level (eg, payor/public policy). Conclusions The waste hospital workers identified differed from previously described waste both in the types of waste described and the emphasis placed on wasted time. The findings of this study represent a possible need for education of hospital workers about known types of waste, an opportunity to assess the impact of novel types of waste described and an opportunity to intervene to reduce the waste identified.

Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds

Attention‐deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood, affecting 5–8% of children. It has been observed that these children have poor sedation experiences; however, to date there is minimal research on procedural sedation in this population.

Do Physicians Underrecognize Obesity

OBJECTIVE: The objective of this study was to develop a reliable and valid checklist for documenting team and collaborative behaviors occurring during multidisciplinary bedside rounds. BACKGROUND: Teamwork and collaboration are important for providing high-quality patient care, yet there are no objective means of evaluating the occurrence of team and collaborative behaviors during bedside rounds. METHODS: A checklist was developed and tested on 3 general medical units. Items on the checklist were derived from the literature and our medical center’s patient-family–centered values. RESULTS: The final version of the checklist was determined to be reliable, valid, and easy to use in the clinical setting. CONCLUSION: Clinicians, administrators, and investigators are encouraged to use and/or modify this checklist for use in their setting. Further research identifying instruments to objectively measure teamwork and collaboration is needed.

Factors associated with emergency department visits in asthma exacerbation

Objectives A physician’s advice is among the strongest predictors of efforts toward weight management made by obese patients, yet only a minority receives such advice. One contributor could be the physician’s failure to recognize true obesity. The objectives of this study were to assess physicians’ ability to recognize obesity and to identify factors associated with recognition and documentation of obesity. Methods Internal medicine residents and attending physicians at three academic urban primary care clinics and their adult patients participated in a study using recognition and documentation of patient obesity as the main measures. Results A total of 52 physicians completed weight assessments for 400 patients. The mean patient age was 51 years, 56% were women, 77% were Hispanic, and 67% had one or more obesity-related comorbidity. There were 192 (48%) patients, of whom 66% were correctly identified by physicians as being obese, 86% of those with a body mass index (BMI) ≥35, but only 49% of those with a BMI of 30 to 34.9 (P < 0.0001). Fewer obese Hispanic patients were identified than were non-Hispanic patients (62% vs 76%; P = 0.03). No physician characteristics were significantly associated with recognition of obesity. Physicians documented obesity as a problem for 51% of patients. Attending physicians documented obesity more frequently than did residents (64% vs 43%, odds ratio 2.5, 95% confidence interval 1.3–4.6) and normal-weight physicians documented obesity more frequently than overweight physicians (58% vs 41%, odds ratio 2.0, 95% confidence interval 1.0–4.0). Documentation was more common for patients with a BMI ≥35 and for non-Hispanics. Documentation was not more common for patients with obesity-related comorbidities. Conclusions Physicians have difficulty recognizing obesity unless patients’ BMI is ≥35. Training physicians to recognize true obesity may increase rates of documentation, a first step toward treatment.