Internal Medicine Residents’ Perceptions of Morning Report: a Multicenter Survey

BackgroundResidents rate morning report (MR) as an essential educational activity. Little contemporary evidence exists to guide medical educators on the optimal content or most effective delivery strategies, particularly in the era of resident duty-hour limitations and shifts towards learner-centric pedagogy in graduate medical education.ObjectiveAssess resident views about MR content and teaching strategies.DesignAnonymous, online survey.ParticipantsInternal medicine residents from 10 VA-affiliated residency programs.Main MeasuresThe 20-item survey included questions on demographics; frequency and reason for attending; opinions on who should attend, who should teach, and how to prioritize the teaching; and respondents’ comfort level with participating in MR. The survey included a combination of Likert-style and multiple-choice questions with the option for multiple responses.Key ResultsA total of 497 residents (46%) completed the survey, with a balanced sample of R1s (33%), R2s (35%), and R3s (31%). Self-reported MR attendance was high (31% always attend; 39% attend > 50% of the time), with clinical duties being the primary barrier to attendance (85%). Most respondents felt that medical students (89%), R1 (96%), and R2/R3s (96%) should attend MR; there was less consensus regarding including attendings (61%) or fellows (34%). Top-rated educational topics included demonstration of clinical reasoning (82%), evidence-based medicine (77%), and disease pathophysiology (53%). Respondents valued time spent on diagnostic work-up (94%), management (93%), and differential building (90%). Overall, 82% endorsed feeling comfortable speaking; fewer R1s reported comfort (76%) compared with R2s (87%) or R3s (83%, p = 0.018). Most (81%) endorsed that MR was an inclusive learning environment (81%), with no differences by level of training.ConclusionsMR remains a highly regarded, well-attended educational conference. Residents value high-quality cases that emphasize clinical reasoning, diagnosis, and management. A supportive, engaging learning environment with expert input and concise, evidence-based teaching is desired.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06351-7.KEY WORDS: graduate medical education, internal medicine residency, morning report, survey     

Internal Medicine Residents’ Perceptions of Virtual Morning Report: a Multicenter Survey

ImportanceThe COVID-19 pandemic disrupted graduate medical education, compelling training programs to abruptly transition to virtual educational formats despite minimal experience or proficiency. We surveyed residents from a national sample of internal medicine (IM) residency programs to describe their experiences with the transition to virtual morning report (MR), a highly valued core educational conference.ObjectiveAssess resident views about virtual MR content and teaching strategies during the COVID-19 pandemic.DesignAnonymous, web-based survey.ParticipantsResidents from 14 academically affiliated IM residency programs.Main MeasuresThe 25-item survey on virtual MR included questions on demographics; frequency and reason for attending; opinions on who should attend and teach; how the virtual format affects the learning environment; how virtual MR compares to in-person MR with regard to participation, engagement, and overall education; and whether virtual MR should continue after in-person conferences can safely resume. The survey included a combination of Likert-style, multiple option, and open-ended questions.ResultsSix hundred fifteen residents (35%) completed the survey, with a balanced sample of interns (39%), second-year (31%), and third-year (30%) residents. When comparing their overall assessment of in-person and virtual MR formats, 42% of residents preferred in-person, 18% preferred virtual, and 40% felt they were equivalent. Most respondents endorsed better peer-engagement, camaraderie, and group participation with in-person MR. Chat boxes, video participation, audience response systems, and smart boards/tablets enhanced respondents’ educational experience during virtual MR. Most respondents (72%) felt that the option of virtual MR should continue when it is safe to resume in-person conferences.ConclusionsVirtual MR was a valued alternative to traditional in-person MR during the COVID-19 pandemic. Residents feel that the virtual platform offers unique educational benefits independent of and in conjunction with in-person conferences. Residents support the integration of a virtual platform into the delivery of MR in the future.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06963-7.KEY WORDS: graduate medical education, internal medicine residency, morning report, virtual     

Residents’ Willingness to Maintain Contracts with Family Doctors: a Cross-sectional Study in China

BackgroundMost previous studies of the family doctor contract services (FDCS) evaluated its quality by using residents’ signing rates, awareness, and satisfaction. We hypothesize that renewal willingness could be another important indicator to examine the quality of FDCS.ObjectiveTo measure residents’ willingness to maintain contracts with family doctors and examine the influencing factors.DesignCross-sectional study.Participants11,250 residents in 31 provincial administrative regions across China.Main MethodsA multistage stratified random sampling method was used to recruit participants. Univariate analysis, mixed-effect regression model analysis, and stepwise multivariate logistic regression analysis were performed to determine the influencing factors of residents’ willingness to maintain contracts with family doctors.Key ResultsAbout 71.3% participants who contracted with and received healthcare services from family doctors were willing to maintain contracts with family doctors in China. Residents registering as local households (OR = 1.192, 95% CI = 1.039–1.368), enrolled in medical insurance (OR = 1.299, 95% CI = 1.011–1.668), reporting better health (OR = 1.246, 95% CI = 1.100–1.413), with shorter walking time to the nearest healthcare center (compared with > 30 min walking time, < 15 min: OR = 1.209, 95% CI = 1.003–1.458; 15–30 min: OR = 1.288, 95% CI = 1.124–1.475), and trusting in (OR = 4.403, 95% CI = 3.849–5.036) and satisfied with (OR = 18.514, 95% CI = 16.195–21.165) their family doctors had significantly higher willingness to maintain contracts with family doctors.ConclusionsResidents’ willingness to maintain contracts with family doctors could be another evaluation indicator of the quality of FDCS in China. Improving the accessibility and quality of healthcare services from family doctors may increase residents’ willingness to keep contracts with family doctors and promote the implementation of FDCS.Supplementary InformationThe online version of this article (10.1007/s11606-020-06306-y) contains supplementary material, which is available to authorized users.KEY WORDS: renewal willingness, family practice, family doctor contract service, influencing factors, Chinese     

Primary Care Tasks Associated with Provider Burnout: Findings from a Veterans Health Administration Survey

Background

The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout.

Objective

To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout.

Design

Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods.

Participants

327 providers from 23 VA primary care practices within one VHA regional network.

Main Measures

The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables.

Key Results

In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b = 4.11, 95% CI = 0.39, 7.83, p = 0.03; educating patients: b = 3.83, 95% CI = 0.33, 7.32, p = 0.03).

Conclusions

Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.

     

The Interrelationships of Coping Styles and Professional Burnout Among Physiotherapists: A Cross-Sectional Study

Burnout is a pathological syndrome in which emotional exhaustion (EE), depersonalization (DEP), and a reduced sense of personal accomplishment (PA) develop in response to prolonged occupational stress. Those working in the physiotherapy profession appear to be at risk for professional burnout brought on by the specific character of the medical professions, involving continuous contact with patients and associated stress, as well as poor working conditions. However, literature data concerning the scale of professional burnout and its psychosocial correlates remain scarce.The aim of the present study was to assess the scale of professional burnout among physiotherapists and to determine the interrelationships between coping styles and burnout symptoms.The sample consisted of 117 professionally active physiotherapists (90 women and 27 men) aged 21 to 55 years (mean [M] 31.88, standard deviation [SD] = 9.14, responsiveness rate of 80.6%) from randomly selected medical institutions of the Lodz Region. The study was conducted using the Maslach Burnout Inventory (MBI) and Coping Inventory for Stressful Situations (CISS) by Endler and Parker. Demographic and job-related data on the respondents were also collected.Task-oriented coping correlated negatively with DEP, EE, and low PA, in contrast to emotion-oriented coping. No correlation was found between avoidance-oriented coping and burnout symptoms. Similarly, no interactive correlations between coping styles and particular burnout symptoms were confirmed.Coping styles correlate independently with professional burnout, without any mutual correlations. Physiotherapists employing a wider spectrum of task-oriented strategies are slightly more satisfied with their job. The incidence of burnout syndrome in the analyzed group is similar to that observed in other medical professions and requires the adoption of preventive measures.     

Nurse Practitioner Autonomy and Relationships with Leadership Affect Teamwork in Primary Care Practices: a Cross-Sectional Survey

BACKGROUND

The Nurse Practitioner (NP) workforce represents a substantial supply of primary care providers able to contribute to meeting a growing demand for care. However, controversy exists regarding the expanding role of NPs in primary care in terms of challenging the teamwork between NPs and physicians. To date, no empirical evidence exists regarding how to promote teamwork in primary care between NPs and physicians.

OBJECTIVE

We investigated whether NP autonomy within primary care practices and the relationships they have with leadership affect teamwork between NPs and physicians.

DESIGN

Using a cross-sectional survey design, data was collected from 163 primary care practices in Massachusetts.

PARTICIPANTS

Three hundred and fourteen primary care NPs completed and returned the mail survey yielding a response rate of 40 %.

MAIN MEASURES

The Autonomy and Independent Practice (AIP) and NP-Administration Relations (NP-AR) scales were used to measure NP independent practice and the relationships with leadership, respectively. These measures were aggregated to the practice level. Teamwork between NPs and physicians was measured at the individual NP level using the Teamwork (TW) scale.

KEY RESULTS

The multilevel linear regression models investigated the influence of practice-level NP autonomy and the relationship between NPs and leadership on teamwork. With every unit increase on the practice-level mean score of AIP centered at the grand mean, the mean TW score increased by 0.271 units (p?<?0.0001). With every unit increase of NP-AR centered at the grand mean, the mean TW score increased by 0.375 (p?<?0.001). Over one-third (41.3 %) of the variance in teamwork could be explained by the final model.

CONCLUSION

The study findings demonstrate that NP autonomy and favorable relationships with leadership improve teamwork. Policy and organizational change should focus on promoting NP autonomy and improving the relationship between NPs and leadership to improve teamwork and consequently improve patient care and outcomes.

     

Spreading Addictions Care Across Oregon’s Rural and Community Hospitals: Mixed-Methods Evaluation of an Interprofessional Telementoring ECHO Program

BackgroundDespite evidence of effectiveness, most US hospitals do not deliver hospital-based addictions care. ECHO (Extension for Community Healthcare Outcomes) is a telementoring model for providers across diverse geographic areas. We developed and implemented a substance use disorder (SUD) in hospital care ECHO to support statewide dissemination of best practices in hospital-based addictions care.ObjectivesAssess the feasibility, acceptability, and effects of ECHO and explore lessons learned and implications for the spread of hospital-based addictions care.DesignMixed-methods study with a pre-/post-intervention design.ParticipantsInterprofessional hospital providers and administrators across Oregon.InterventionA 10–12-week ECHO that included participant case presentations and brief didactics delivered by an interprofessional faculty, including peers with lived experience in recovery.ApproachTo assess feasibility and acceptability, we collected enrollment, attendance, and participant feedback data. To evaluate ECHO effects, we used pre-/post-ECHO assessments and performed a thematic analysis of open-ended survey responses and participant focus groups.Key ResultsWe recruited 143 registrants to three cohorts between January and September 2019, drawing from 32 of Oregon’s 62 hospitals and one southwest Washington hospital. Ninety-six (67.1%) attended at least half of ECHO sessions. Participants were highly satisfied with ECHO. After ECHO, participants were more prepared to treat SUD; however, prescribing did not change. Participants identified substantial gains in knowledge and skills, particularly regarding the use of medications for opioid use disorder; patient-centered communication with people who use drugs; and understanding harm reduction as a valid treatment approach. ECHO built a community of practice and reduced provider isolation. Participants recognized the need for supportive hospital leadership, policies, and SUD resources to fully implement and adopt hospital-based SUD care.ConclusionsA statewide, interprofessional SUD hospital care ECHO was feasible and acceptable. Findings may be useful to health systems, states, and regions looking to expand hospital-based addictions care.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06175-5) contains supplementary material, which is available to authorized users.KEY WORDS: substance-related disorders, hospitalization, substance use treatment, ECHO model, continuing medical education, case-based learning     

The Association Between Self-Rated Mental Health Status and Total Health Care Expenditure: A Cross-Sectional Analysis of a Nationally Representative Sample

Both clinical diagnoses and self-rated measures of mental illness are associated with a variety of outcomes, including physical well-being, health utilization, and expenditure. However, much of current literature primarily utilizes clinically diagnosed data.This cross-sectional study explores the impact of mental illness and health care expenditure using 2 self-rated measures: self-rated measured of perceived mental health status (SRMH) and Kessler Screening Scale for Psychological Distress (K6).Data from the 2011 Medical Expenditure Panel Survey Household Component, a nationally representative sample of noninstitutionalized individuals (n = 18,295), were analyzed using bivariate χ² tests and a 2-part model (logistics regression and generalized linear model regression for the first and second stages, respectively).Although predictive of any health expenditure, SRMH alone was not highly predictive of the dollar value of that health expenditure conditional on any spending. By comparison, the K6 measure was significantly and positively associated with the probability of any health expenditure as well as the dollar value of that spending. Taken together, both the K6 and SRMH measures suggest a positive relationship between poor mental health and the probability of any health expenditure and total expenditure conditional on any spending, even when adjusting for other confounding factors such as race/ethnicity, sex, age, educational attainment, insurance status, and some regional characteristics.Our results suggest that psychological distress and SRMH may represent potential pathways linking poor mental health to increased health care expenditure. Further research exploring the nuances of these relationships may aid researchers, practitioners, and policy makers in addressing issues of inflated health care expenditure in populations at risk for poor mental health.     

Association Between Conflicts of Interest and Authors’ Positions on Harms of Varenicline: a Cross-Sectional Analysis

BackgroundFew studies have investigated the relationship between industry funding/conflicts of interest and authors’ positions in opinion pieces on drug safety. Harmful effects of varenicline, a treatment for smoking cessation, have been highly contested.ObjectiveTo examine the association between pharmaceutical industry funding/authors’ financial conflicts of interest and position on varenicline in opinion articles, especially in relation to the minimization of harms; to assess whether opinion pieces on drug safety issues written by authors with conflicts of interest are more frequently cited in the news or social media.DesignCross-sectional analysis.ParticipantsEnglish language opinion pieces and narrative reviews about varenicline published between May 2006 and February 2019.Main MeasuresOdds ratios and 95% confidence intervals; the Mann-Whitney two-sample statistic was used to test for differences in Altmetric scores, a measure of media attention.Key ResultsOf the 221 included articles, 30.3% (67) disclosed the funding source and 62.9% (139) disclosed authors’ conflicts of interest. Authors of opinion pieces on varenicline who reported financial ties to the pharmaceutical industry (as a conflict of interest or funding source) were more likely to minimise the cardiovascular and psychiatric risk of varenicline compared to those without conflicts of interest or industry funding (OR: 4.00; 95% CI: 1.32 to 12.16 for cardiovascular risk; OR: 8.51; 95% CI: 3.79 to 19.11 for psychiatric risk). These associations persisted in sensitivity analyses. No statistically significant difference in Altmetric score was found between articles with (mean 15.83, median 3) and without (mean 11.90, median 1) conflicts of interest, indicating similar media attention (p-value=0.11).ConclusionsWe found that authors with financial ties to drug companies were more likely to publish opinion pieces that minimised harms of varenicline. These results raise questions about journals’ editorial policies to accept reviews of treatments from authors with financial relationships with manufacturers.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06915-1.KEY WORDS: conflict of interest, pharmaceutical industry, drug safety     

Frequency and Pattern of Emergency Department Visits by Long‐Term Care Residents—A Population‐Based Study

OBJECTIVES: To obtain population‐based estimates of emergency department (ED) visits by long‐term care (LTC) residents. DESIGN: Retrospective cohort study using administrative data. SETTING: All LTC facilities in Ontario, Canada. PARTICIPANTS: All LTC residents who visited an ED at least once during a 6‐month period. MEASUREMENTS: All ED visits were described using the National Ambulatory Care Reporting System. Two distinct visit types were defined. Potentially preventable visits were defined as those for any ambulatory care sensitive condition; these are conditions for which exacerbations that result in hospital use suggest lack of access to adequate primary care. Low‐acuity visits were defined as those triaged as nonurgent at ED registration and ended with return to the LTC facility without hospital admission. RESULTS: Nearly one‐quarter of LTC residents visited the ED at least once in 6 months. Of all visits, 24.6% were for a potentially preventable reason, most commonly pneumonia, urinary tract infection, and congestive heart failure. These visits had a high frequency of ambulance transport (90.4%), emergent triage (35.3%), hospital admission (62.4%), and death within 30 days (23.6%). Of all visits, 11.0% were low acuity. Fall‐related injury was the most common cause. Low‐acuity visits were the shortest (mean length 4.5 ± 4.0 hours) and had the lowest frequency of death within 30 days (4.3%). CONCLUSION: LTC residents made frequent visits to the ED. The visit types showed distinct patterns that suggest a need for better access to medical care for common conditions and a greater emphasis on fall prevention in LTC.     

RETRACTED ARTICLE: Doctors’ and Patients’ Perceptions of Impacts of Doctors’ Communication and Empathy Skills on Doctor–Patient Relationships During COVID-19

BackgroundDuring the COVID-19 pandemic, the performance of Chinese doctors may have led to improved doctor–patient relationships (DPRs). However, it is unclear how doctors and patients perceived the impact of doctors’ communication and empathy skills on DPRs during the COVID-19 pandemic.ObjectiveTo examine the perceptions of doctors and patients on how doctors’ communication skills and empathy skills influence DPRs during COVID-19.Main MeasuresDoctors’ and patients’ perceptions of doctors’ communication skills were measured using the Chinese version of the SEGUE Framework. To measure empathy skills and DPRs, the Jefferson Scale of Empathy and Difficult Doctor-Patient Relationship Questionnaire were administered to doctors, and the Consultation and Relational Empathy Measure and Patient-Doctor Relationship Questionnaire were administered to patients.ResultsA total of 902 doctors and 1432 patients in China were recruited during the pandemic via online or offline surveys (overall response rate of 69.8%). Both doctors and patients rated doctors’ empathy skills as more impactful on DPRs than communication skills. Doctors believed that only their empathy skills influenced DPRs. But patients believed that there was a significant bi-directional relationship between doctors’ communication and empathy skills and these two skills interacted to directly and indirectly influence DPRs, and doctors’ empathy had a greater mediating effect than their communication.ConclusionsDuring COVID-19, there were both similarities and differences between Chinese doctors’ and patients’ views on how doctors’ communication and empathy skills influenced DPRs. The greater effect of doctors’ empathy skills suggests that both doctors and patients attach more importance to doctors’ empathy in doctor–patient interactions. The bi-directional effect on patient outcomes suggests that both doctors’ communication and empathy skills are important to patients’ perceptions of DPRs.KEY WORDS: Doctor–patient relationship, Doctors’ communication skills, Doctors’ empathy skill, COVID-19, China     

A Cross-Sectional Study of Depressive Symptoms and Risky Alcohol Use Behaviors Among HIV Primary Care Patients in New York City

An association between problem drinking and depression among HIV-infected individuals has been previously demonstrated; however, which specific risky drinking behaviors are associated with higher levels of depression has not yet been investigated. Using an adult sample of HIV-infected primary care patients (78% male, 94% Black or Hispanic), we investigated whether depressive symptoms are associated with various risky drinking behaviors. Participants were administered the Beck Depression Inventory-II to assess depressive symptoms, and the Alcohol Use Disorders and Associated Disabilities Interview Schedule-IV to evaluate alcohol involvement. Participants with depressive symptoms (26%) were at higher risk for alcohol dependence [adjusted odds ratio (AOR) 3.8; 95% CI 2.0–7.2], regular binge drinking (AOR 2.0; 95% CI 1.1–3.8), and regular daytime drinking (AOR 2.1; 95% CI 1.2–3.8), in comparison with their non-depressed counterparts. Because both depression and unhealthy drinking negatively affect medication adherence and clinical outcomes, a better understanding of the association between depression and certain risky drinking behaviors among HIV-infected individuals is vital to improving their care and prognoses.