Do Standardized Patients Have Concerns About Students Not Captured by Traditional Assessment Forms?

Construct: Traditionally, standardized patients (SPs) assess students' clinical skills principally through numerical rating forms—an approach that may not fully capture SPs' concerns. SPs are students' closest approximation to real patients. To maximally benefit students' clinical training and evaluation it is important to find ways to give voice to the totality of SPs' perspectives. Background: SPs have been shown to be a reliable and valid means to assess medical students' clinical skills in clinical skills examinations. We noticed, however, that SPs often express “off the record” concerns about students, which they do not include on traditional assessment forms. Approach: To explore these “off the record” concerns, we designed a Concerns item and added it to the traditional assessment form for an end-of-3rd-year clinical skills examination shared by three medical schools. We asked SPs to use this Concerns item to identify students about whom they had any “gut-level” concerns and provided them with a narrative opportunity to explain why. SPs were informed that the purpose of the item was to help students with difficulties and was not part of the student's grade. Results: We analyzed the concerns data using quantitative and qualitative methods. Of 551 students at three schools, 223 (～40%) had concerns recorded. Seventy students received two or more concerns. Qualitative analysis of SPs' comments revealed 3 major categories of concern: communication and interpersonal skills, history taking, and physical exam. Grouped under each were several subcategories. More than half of the written comments from the SPs related to the communication/interpersonal skills category and included subcategories commonly addressed in communications courses: lack of empathy, good listening skills, and lack of connection to the patient. They also included subcategories that in our experience are less commonly addressed: odd or off-putting mannerisms, lack of confidence, unprofessional behavior, domineering behavior, and biased behavior. Another 47% of concerns identified deficiencies in history taking and physical examination. Of the students with concerns noted by two or more SPs, SPs' narrative comments on 84%, 42%, and 48% of the students in the domains of communications, history, and physical exam respectively indicated potential problems not identified by scores on the traditional assessment form. Conclusion: The Concerns item is a narrative assessment method that may add value to traditional quantitative scoring by identifying and characterizing problematic student performance not captured by the traditional assessment form. It may thus contribute to giving fuller voice to the totality of SPs' perspective.     

Do Emergency Physicians Improve the Appropriateness of Emergency Transfer in Rural Areas?

Background

Until recently, there have been few studies on the transfer of patients from emergency departments (EDs) overall, as such studies were limited primarily to trauma patients.

Do Experiences Consistent With a Medical-Home Model Improve Diabetes Care Measures Reported by Adult Medicaid Patients?

OBJECTIVE

The patient-centered medical home has gained much traction. Little is known about the relationship between the model and specific health care processes for chronic diseases such as diabetes. This study assesses the impact of features of a medical home on diabetes care.

RESEARCH DESIGN AND METHODS

A cross-sectional survey of 540 patients with Medicaid (Medi-Cal) health insurance and type 2 diabetes in Los Angeles County was performed. The Primary Care Assessment Tools was used to measure seven features of medical-home performance.

RESULTS

The response rate of the patient survey was 68.9%. Patient-reported medical-home performance averaged a score of 2.85 ± 0.29 (on a 1–4 scale, with 4 equaling the best care). Patients who received more timely and thorough diabetes care reported higher medical-home performance in every feature except for the comprehensiveness-services available. For example, the first-contact access feature score was higher among patients who had an HbA_1c test in the past 6 months versus those who did not (2.38 vs. 2.25; P < 0.05). Before and after adjusting for sociodemographics and health status, total medical-home performance was positively associated with each diabetes care measure. A 1-point increase in total medical-home score was associated with 4.53 higher odds of an HbA_1c test in the past 6 months and 1.88 higher odds of an eye exam in the past year.

CONCLUSIONS

Features consistent with higher medical-home performance are associated with improvements in patient-reported diabetes care process measures, even in this low socioeconomic status setting. The patient-centered medical-home model may help in caring for people with type 2 diabetes.     

Evaluation of Obstructive Sleep Apnea in Female Patients in Primary Care: Time for Improvement?

Obstructive sleep apnea (OSA) has historically been regarded as a male disease. However, there are a number of significant gender-related differences in the symptoms, diagnosis, and consequences of OSA, which seems to be more severe in male than in female patients, although this sex difference decreases with increasing age. Female patients with OSA tend to present nonspecific symptoms, such as insomnia, depressive symptoms, fatigue, morning headache, and nightmares, often resulting in underdiagnosis and undertreatment compared to male patients. Understanding these differences in women is essential for early identification and referral of patients for diagnosis and treatment of OSA.     

Triaging Herpes Zoster Ophthalmicus Patients in the Emergency Department: Do All Patients Require Referral?

Objectives: The objective was to assess the predictive value of clinical signs and symptoms of herpes zoster ophthalmicus (HZO) for development of moderate to severe eye disease. Methods: This was a prospective cohort multicenter study of 54 patients referred to the ophthalmology service after presenting to the emergency department (ED) or primary care clinic with a zosteriform rash of less than 10 days’ duration. Upon referral to ophthalmology, easily assessable clinical signs and symptoms were documented. A complete ocular exam was then performed. Patients were followed for 2 months. Results: Twenty‐three patients (43%) developed moderate to severe disease as defined by corneal or intraocular involvement. Eye redness and rash in the supratrochlear nerve distribution had a statistically significant association with clinically relevant eye disease. All 23 patients who developed moderate to severe eye disease presented with a red eye. Hutchinson’s sign (nasociliary nerve involvement) was not predictive of clinically relevant eye disease. Conclusions: Eye redness was 100% sensitive for predicting moderate to severe eye disease in this sample of patients and should necessitate immediate referral for ophthalmologic assessment. Patients lacking eye redness, even with a positive Hutchinson’s sign, may not require immediate specialist consultation. All patients not being referred require careful instructions to seek further care should they develop any concerning eye symptoms such as redness, pain, photophobia, or visual disturbance. ACADEMIC EMERGENCY MEDICINE 2010; 17:1183–1188 © 2010 by the Society for Academic Emergency Medicine     

Qualitative Change in Migraine Prevention?

A new generation of drugs that target calcitonin gene‐related peptide (CGRP) pathways offers a unique opportunity to explore the relationship between responder rates (RRs) and improvement in patient outcomes. The authors hypothesize a “tipping point” exists for patients with a ≥75% migraine response. They propose higher RRs reported in trials with CGRP inhibitory antibodies deliver not only a quantitative change in monthly headache days, but also a qualitative change in function, for a clinically meaningful subpopulation of patients.     

Reflections and Speculations on Refractory Migraine: Why Do Some Patients Fail to Improve With Currently Available Therapies?

This review considers current debate surrounding refractory migraine and poses the question, why do some patients fail to improve with currently available therapies?     

Constipation in Palliative Care: What Do We Use as Definitions and Outcome Measures?

ContextAdvances in the management of constipation in palliative care remain hindered by the lack of agreed-upon diagnostic criteria.ObjectivesThe objective of this work was to emphasize this issue by systematically examining the eligibility and primary outcome measures in studies of constipation in the hospice and palliative care population.MethodsA palliative care-specific electronic literature search was undertaken using the validated domain filter “palliative care” and topic filter “constipation” in CareSearch (www.caresearch.com.au), which interrogates PubMed in real time (1965–2011). Studies were included if they were primary reports of the treatment of constipation in a palliative care setting. Articles could be prospective or retrospective; randomized controlled trials, cohort studies, or case series.ResultsTwenty articles on the palliative care population were included in which there were six different definitions of constipation. Only 12 of 20 articles used their cited definitions of constipation as the studies' primary outcome measures and four of four blinded, randomized, controlled trials. Articles that used the time between bowel actions or the use of laxatives as the definition of constipation were most likely to report outcomes based on these criteria.ConclusionConstipation is a significant problem in palliative care; however, not having an agreed-upon definition limits research initiatives and the ability to apply these results clinically to people with constipation. Four domains are suggested as pivotal to the diagnosis: any life-long history of constipation (using the Rome Criteria), evaluation of physical changes that may cause or worsen constipation, the subjective sensation (such as feelings of incomplete defecation or bloating or fullness), and objective changes (such as frequency or consistency of stools).     

Do Bubble Characteristics Affect Recanalization in Stroke Patients Treated with Microbubble-Enhanced Sonothrombolysis?

Administration of microbubbles (MB) may augment the effect of ultrasound-enhanced systemic thrombolysis in acute stroke. Bubble structural characteristics may influence the effect of MB on sonothrombolysis. We aimed to compare the effects of galactose-based air-filled MB (Levovist) and sulphur hexafluoride-filled MB (Sonovue) on recanalization and clinical outcome. One hundred thirty-eight i.v. recombinant tissue plasminogen activator-(tPA-) treated patients with middle cerebral artery (MCA) occlusion were studied. Presence and location of arterial occlusion and recanalization (RE) were assessed using the thrombolysis in brain ischemia (TIBI) flow grading system. Patients underwent 2 h of continuous transcranial Doppler (TCD) monitoring and received three bolus of MB after 2, 20 and 40 min of tPA bolus. Ninety-one patients received Levovist (LV) and 47 received Sonovue (SV). NIHSS scores were obtained at baseline and after 24 h. Modified Rankin Scale (mRS) score was used to assess outcome at 3 mo. Median admission NIHSS was 17. On TCD, 96 (69.6%) patients had a proximal and 42 (30.4%) a distal MCA occlusion. Age, baseline NIHSS, clot location, stroke subtypes and time to treatment were similar between LV and SV groups. Recanalization rates after 1 h (32.2%/35.6%), 2 h (50.0%/46.7%) and 6 h (63.8%/54.5%) were similar in LV/SV groups (p > 0.3). Clinical improvement (NIHSS decrease >or= 4 points) at 24 h was similar in both groups (54.9%/51.1%, p = 0.400), as well as symptomatic intracranial haemorrhage rate (3.3%/2.1%, p = 0.580) and in-hospital mortality (8.1%/9.3%, p = 0.531). Similarly, the type of MB administered did not affect long-term outcome after sonothrombolysis. Forty-four percent of patients in the LV group and 48.5% in the SV group achieved functional independence (mRS 相似文献