Service and Education: The Association Between Workload,Patient Complexity,and Teaching on Internal Medicine Inpatient Services

Background

Attending rounds remain the primary venue for formal teaching and learning at academic medical centers. Little is known about the effect of increasing clinical demands on teaching during attending rounds.

Objective

To explore the relationships among teaching time, teaching topics, clinical workload, and patient complexity variables.

Design

Observational study of medicine teaching teams from September 2008 through August 2014. Teams at two large teaching hospitals associated with a single medical school were observed for periods of 2 to 4 weeks.

Participants

Twelve medicine teaching teams consisting of one attending, one second- or third-year resident, two to three interns, and two to three medical students.

Main Measures

The study examined relationships between patient complexity (comorbidities, complications) and clinical workload variables (census, turnover) with educational measures. Teams were clustered based on clinical workload and patient complexity. Educational measures of interest were time spent teaching and number of teaching topics. Data were analyzed both at the daily observation level and across a given patient’s admission.

Key Results

We observed 12 teams, 1994 discussions (approximately 373 h of rounds) of 563 patients over 244 observation days. Teams clustered into three groups: low patient complexity/high clinical workload, average patient complexity/low clinical workload, and high patient complexity/high clinical workload. Modest associations for team, patient complexity, and clinical workload variables were noted with total time spent teaching (9.1% of the variance in time spent teaching during a patient’s admission; F[8,549]?=?6.90, p <?0.001) and number of teaching topics (16% of the variance in the total number of teaching topics during a patient’s admission; F[8,548]?=?14.18, p <?0.001).

Conclusions

Clinical workload and patient complexity characteristics among teams were only modestly associated with total teaching time and teaching topics.

     

Physicians' Attitudes and the Use of Oral Anticoagulants: Surveying the Present and Envisioning Future

Atrial fibrillation has the highest prevalence in the elderly. While the elderly are at the highest risk for stroke and would benefit the most from anticoagulation, they are also the least likely to receive anticoagulation. In a pooled analysis of the primary prevention trials, warfarin reduced stroke by 68% compared with placebo, and aspirin reduced stroke by 18%. Age, history of hypertension, diabetes, heart failure or reduced left ventricular function, and previous transient ischemic events and stroke are independent risk factors for stroke in patients with atrial fibrillation. Less than 50% of the elderly who have clear-cut indications and no contraindications for warfarin receive anticoagulant therapy. This low use of warfarin is driven by many factors, but physicians' fear of hemorrhage is among the most important. Better adherence to evidence-driven guidelines, better patient and physician education, point-of-care monitoring of INR and the future development of user friendly anticoagulant drugs are likely to result in higher rates of anticoagulation use.     

Age-determined expression of priming protease TMPRSS2 and localization of SARS-CoV-2 in lung epithelium

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) novel coronavirus 2019 (COVID-19) global pandemic has led to millions of cases and hundreds of thousands of deaths. While older adults appear at high risk for severe disease, hospitalizations and deaths due to SARS-CoV-2 among children have been relatively rare. Integrating single-cell RNA sequencing (scRNA-seq) of developing mouse lung with temporally resolved immunofluorescence in mouse and human lung tissue, we found that expression of SARS-CoV-2 Spike protein primer TMPRSS2 was highest in ciliated cells and type I alveolar epithelial cells (AT1), and TMPRSS2 expression increased with aging in mice and humans. Analysis of autopsy tissue from fatal COVID-19 cases detected SARS-CoV-2 RNA most frequently in ciliated and secretory cells in airway epithelium and AT1 cells in peripheral lung. SARS-CoV-2 RNA was highly colocalized in cells expressing TMPRSS2. Together, these data demonstrate the cellular spectrum infected by SARS-CoV-2 in lung epithelium and suggest that developmental regulation of TMPRSS2 may underlie the relative protection of infants and children from severe respiratory illness.     

Loneliness and its Association with Health Behaviors in People with a Lived Experience of a Serious Mental Illness

To explore the association between loneliness and efficacy to engage in health behaviors that are known to reduce the risk of early mortality in people with serious mental illness (SMI). This secondary data analysis was based on a cross-sectional study of 113 participants with SMI residing in New Hampshire. Ordinary Least Squares regressions were used to examine bivariate relationships between variables of interest. Participants had a primary mental health diagnosis of major depressive disorder (37.2%), schizophrenia spectrum disorder (28.3%), bipolar disorder (29.2%), or posttraumatic stress disorder (5.3%). High levels of loneliness were associated with low levels of self-efficacy to manage chronic diseases (p =?0.0001), as well as low levels of self-efficacy to manage psychological well-being (R² =?.31; F =?9.49, p =?0.0001; RMSE =?1.66). Loneliness may serve as a barrier to healthy behaviors, and thus, contribute to early mortality among people with SMI. The growing body of literature that demonstrates the importance of addressing loneliness in people with SMI should stimulate policymakers and researchers to target loneliness as a mechanism to address early mortality in people with SMI.

     

Core Motivations of Childhood Obsessive-Compulsive Disorder: The Role of Harm Avoidance and Incompleteness

Child Psychiatry & Human Development - In an effort to improve patient conceptualization and targeted treatment, researchers have sought to accurately classify OCD subtypes. To date, the most...     

Prospective Relations between Social Comparison Orientation and Weight Loss Outcomes

Abstract

Maintenance of weight loss after behavioral intervention tends to be poor, and there is need for an improved understanding of factors that are associated with successful maintenance. Social comparison is known to be a powerful influence on treatment outcomes for group-based behavioral weight loss programs, but little is known about the role of individual differences in social comparison orientation (i.e., tendency to value comparison information) in this context. The goal of this study was to examine prospective relations between social comparison orientation and long-term weight loss outcomes (percent weight loss and aerobic-intensity physical activity) among participants in behavioral weight loss treatment. Participants (n?=?161, M_Age?=?54, M_BMI?=?34.4?kg/m²) completed a measure of social comparison orientation at pre-treatment baseline. Height and weight were measured in the research center and aerobic-intensity physical activity was assessed via accelerometer at baseline, mid- and end-of-treatment, and at 6 and 12 months post-treatment (representing maintenance). Multilevel models tested prospective relations between comparison orientation and treatment outcomes over time, with emphasis on differences during the post-treatment maintenance phase. Stronger (vs. weaker) general comparison orientation was associated with better maintenance of aerobic-intensity physical activity. However, stronger (vs. weaker) orientation toward comparisons with better-off others (i.e., upward comparison) was associated with less weight loss success during and after treatment. Social comparison orientation thus shows meaningful relations with long-term maintenance of key outcomes in group-based behavioral weight loss treatment, and warrants further investigation in this context.