Clinical Case Conferences Research Articles

965. Advanced Practice Providers in Infectious Disease: Educational Needs and Opportunities

BackgroundAdvanced Practice Providers (APPs) practice throughout Infectious Disease (ID) in a variety of settings through interprofessional collaboration with physicians, pharmacists, and other team members. However, there is a paucity of specific and directed educational opportunities available for APPs within ID. In order to better understand this, we examined specific APP educational needs and how educational programs could provide high quality opportunities for APPs in ID.MethodsVoluntary anonymous surveys were created in the REDCap data tool and distributed by email lists, social media, and Infectious Diseases Society of America community forums to APPs working in ID.ResultsNinety-nine APPs responded to the survey (figure 1). 97% (96) of respondents were interested in APP specific ID educational opportunities. Of respondents, 76% (74) felt ID specific podcasts would be most helpful, while 86% (84) noted that access to ID clinical case conferences or self-directed, online modules would be instructive (figure 2). 91% (90) did not attend IDWeek annually due to various barriers, including lack of clinical coverage and cost associated with the conference (figure 3) despite 89% (88) receiving Continuing Education (CE) reimbursement. 64% (62) respondents were interested in future APP mentorship opportunities, from either more senior APPs or physicians. Figure 1. Geographic Distribution of Respondents, n=99 ConclusionAPPs provide collaborative and specialized ID care in a variety of settings. However, continued educational needs specifically for APPs have been identified. From survey respondents, the majority of APPs did not attend IDWeek, a sentinel ID education event, citing clinical coverage and cost being significant barriers. This represents an opportunity for clinically focused educational opportunities, both at IDWeek and also through other platforms, particularly since many APPs receive CE funding from their employers. Podcasts, online lecture series, and self-study certificate programs were identified as avenues for ID teaching and also present accessible, alternative methods for training. Ultimately, as the growing APP workforce continues to provide patient care in a variety of ID settings, educational opportunities with mentorship are necessary to support them in their practice. Disclosures Steven A. Pergam, MD, MPH, Chimerix Inc. (Other Financial or Material Support, Clinical Trial)Global Life Technologies, Inc. (Grant/Research Support)Merck and Co. (Other Financial or Material Support, Clinical Trial) Steven A. Pergam, MD, MPH, Chimerix (Individual(s) Involved: Self): Clinical Trial; Global Life Technologies, Inc (Individual(s) Involved: Self): Research Grant or Support; Merck & Co. (Individual(s) Involved: Self): Scientific Research Study Investigator; Sanofi Aventis (Individual(s) Involved: Self): Other Financial or Material Support, Provided vaccines for clinical trial sponsored by the NIH

Understanding how to improve the use of clinical coordination mechanisms between levels of care

Abstract Background Clinical coordination mechanisms (CCM) can play an important role in improving clinical coordination between primary (PC) and secondary care (SC) doctors, being necessary to understand the reasons hindering their use. The aim is to analyse the level of use of CCM, and the difficulties and factors associated to it. Methods Cross-sectional study based on an online survey using the COORDENA-CAT questionnaire (October-December 2017). Sample: 3308 doctors of the Catalan national health system. Outcome variables: frequent use of six CCM and difficulties in their use. Explanatory variables: sociodemographic, labour characteristics, organizational and interactional factors. Stratification variable: level of care. Analysis: descriptive bivariate and multivariate by logistic regression. Results The level of use differed according to the CCM and level of care, being lower for the different cross-level consultations (via electronic medical record -EMR: 52.36%, email: 26.11% and phone: 21.73%). Shared EMR of the organisation (81.27%) and of the region (65.89%), and joint clinical case conferences (63.28%) were the most frequently used, especially by PC doctors, and the ones presenting more difficulties in use. While the difficulties pointed to organizational problems, mostly related to computer and schedule problems, the analysis of factors pointed also to some individual factors. Working in integrated areas or with local hospitals were factors positively associated with the use of CCM. Interactional factors, such as personally knowing the other level doctor, were associated among SC doctors. Conclusions The use of CCM differed across mechanisms and level of care, and was clearly improvable. Difficulties and factors affecting their use were mostly organizational, so managerial support is required to create the appropriate conditions for their use. It is also important to strengthen interaction between doctors of different care levels to improve the use of CCM. Key messages The level of use of CCM differed according to the mechanism and level of care, and was clearly improvable. This study identifies difficulties and factors affecting their use, mainly organizational. These results are useful for managers promoting strategies to improve clinical coordination by the effective implementation of CCM, which require managerial support and interaction between doctors.

State of implementation of clinical ethics case conferences by visiting nurse station managers and their needs for support

State of implementation of clinical ethics case conferences by visiting nurse station managers and their needs for support

Examination of Factors Related to Stress Associated with the Role of Ethics Coordination in Clinical Ethics Case Conferences for Nursing Managers of Home-Visit Nursing Stations

Examination of Factors Related to Stress Associated with the Role of Ethics Coordination in Clinical Ethics Case Conferences for Nursing Managers of Home-Visit Nursing Stations

Fostering Certainty in an Uncertain Era of Virtual Residency Interviews.

Fostering Certainty in an Uncertain Era of Virtual Residency Interviews.

Do primary and secondary care doctors have a different experience and perception of cross-level clinical coordination? Results of a cross-sectional study in the Catalan National Health System (Spain)

BackgroundClinical coordination across care levels is a priority for health systems around the world, especially for those based on primary health care. The aim of this study is to analyse the degree of clinical information and clinical management coordination across healthcare levels in the Catalan national health system experienced by primary (PC) and secondary care (SC) doctors and explore the associated factors.MethodsCross-sectional study based on an online survey using the self-administered questionnaire COORDENA-CAT. Data collection: October–December 2017. Study population: PC and SC (acute and long term) doctors of the Catalan national health system. Participation rate was 21%, with a sample of 3308 doctors. Outcome variables: cross-level clinical information coordination, clinical management coordination, and perception of cross-level coordination within the area. Explanatory variables: socio-demographic, employment characteristics, attitude towards job, type of area (according to type of hospital and management), interactional factors, organizational factors and knowledge of existing coordination mechanisms. Stratification variable: level of care. Descriptive and multivariate analysis by logistic regression.ResultsThe degree of clinical coordination experienced across levels of care was high for both PC and SC doctors, although PC doctors experienced greater exchange and use of information and SC doctors experienced greater consistency of care. However, only 32.13% of PC and 35.72% of SC doctors found that patient care was coordinated across care levels within their area. In both levels of care, knowing the doctors of the other level, working in an area where the same entity manages SC and majority of PC, and holding joint clinical case conferences were factors positively associated with perceiving high levels of clinical coordination. Other associated factors were specific to the care level, such as being informed of a patient’s discharge from hospital for PC doctors, or trusting in the clinical skills of the other care level for SC doctors.ConclusionsInteractional and organizational factors are positively associated with perceiving high levels of clinical coordination. Introducing policies to enhance such factors can foster clinical coordination between different health care levels. The COORDENA questionnaire allows us to identify fields for improvement in clinical coordination.

Associated factors to the perception of clinical coordination in the Catalan national health system

Abstract Background Clinical coordination across levels of care is a priority for health systems. The aim is to analyse the factors associated to a high perception of clinical coordination of primary (PC) and secondary care (SC) doctors of the Catalan national health system (NHS). Methods Cross-sectional study based on the self-administered online questionnaire COORDENA-CAT. Data collection: October-December 2017. Study population: PC and SC (acute and long term) doctors of the public Catalan NHS that had been working for at least one year in the organization, had direct contact with patients and related with doctors of the other level of care. The participation rate was 20.5%, with a sample of 3308 doctors. Outcome variable: perception of clinical coordination across levels of care. Explanatory variables: socio-demographic, employment characteristics, attitude towards work, type of area (according to type of hospital and managing entity), interactional factors, organizational factors and knowledge of existing coordination mechanisms. Stratification variable: level of care. Descriptive and multivariate analysis by logistic regression. Results Only 32.13% of PC doctors and 35.72% of SC doctors found that patient care was coordinated across care levels within their area. In both levels of care, knowing the doctor of the other level; finding that their practice influences the other care level; finding that the organization’s management facilitates coordination; working in an area where the same entity manages SC and majority of PC and to hold joint clinical case conferences are factors positively associated to a high perception of clinical coordination. Besides, there are other positively associated factors exclusive for each level of care. Conclusions Several common interactional and organizational factors are positively associated to a high perception of care coordination. Introducing policies to enhance such factors can foster care coordination in the Catalan NHS. Key messages This study found out factors associated to clinical coordination across care levels in each level. It helps to develop specific coordination policies by level of care to address those factors.

Implementing the START:AV in a Dutch residential youth facility: Outcomes of success.

Currently, implementation research in the field of forensic risk assessment is limited and consensus on “implementation success” is lacking. This study applies outcomes of success from implementation science to the implementation evaluation of the Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV) in a residential youth care facility in the Netherlands. Staff perceptions on the implementation and the instrument were assessed using 5 implementation outcomes in a longitudinal multimethod design: acceptability, adoption, appropriateness, feasibility, and penetration. As anticipated, the majority of staff perceived START:AV core constructs as useful for treatment (appropriateness). However, satisfaction with the instrument decreased over time (acceptability). This was likely due to an increased workload (feasibility). Despite this dissatisfaction, the completion rate was acceptable (adoption). Lastly, staff reported a lack of integration of the START:AV findings in clinical case conferences (penetration). The implementation outcomes aid in identifying areas for improvement, which in turn can lead to an increased and more consistent uptake of structured risk assessment into routine practice

The Influence of Early Ophthalmic Hospitals on the Journal

To consider the American Journal of Ophthalmology's (AJO's) role not only as a forum to describe clinical and scientific advances but also as a record of institutional histories. We used the New York Eye and Ear Infirmary of Mount Sinai, the Massachusetts Eye and Ear Infirmary, and the Wills Eye Hospital as case studies on the Journal's role in documenting the people and organizations that have moved ophthalmology forward. Perspective. Using the ScienceDirect database, we conducted a literature search to gather all mentions of the 3 eye hospitals in the Journal's archives from 1918 to 2018. We evaluated those search results to identify a few of the individuals and articles that highlight how the history of eye institutions are reflected in the AJO. Searches for the aforementioned 3 hospitals yielded over 3400 results in Journal archives. These included articles on their histories, proceedings from clinical case conferences, profiles of prominent surgeons, and information about educational offerings, among others. Many of those articles were written by physicians from those institutions who also served on the AJO's editorial board or had a long history of publishing in the Journal. The AJO has played a crucial role in the last 100 years as a register of ophthalmic history. The New York Eye and Ear Infirmary of Mount Sinai, Massachusetts Eye and Ear Infirmary, and Wills Eye Hospital provide 3 examples of how that role manifests.

The geriatric information flow model

An abstract information flow model is proposed for geriatric care, the geriatric information flow model (GIFM) by adopting an information model from cancer care and introduce characteristics for geriatric care (patient population, multidisciplinary and multi-professional approach, cross-sectoral approach). The ideal-typical geriatric patient treatment process flow is introduced. Actors (patients, physicians, therapists, organizations), information objects, and information relations as well as information flows are defined. Process flow, actors, information object, and information relations are proved with qualitative material from an accompanying study. The GIFM is validated by mapping four typical knowledge processes (multi-professional geriatric team session, interdisciplinary clinical case conferences, tumor boards, transition management) onto the model. The GIFM is stated as useful for understanding information flows and relations in geriatric care. All processes for validation can be mapped onto GIFM. In future work the GIFM should be tested with more knowledge process and could also be used for identifying gaps in the IT support of geriatric care. A study on high and low information quality in geriatric care is also proposed.

Doctors\u2019 opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system

BackgroundClinical coordination is considered a health policy priority as its absence can lead to poor quality of care and inefficiency. A key challenge is to identify which strategies should be implemented to improve coordination. The aim is to analyse doctors’ opinions on the contribution of mechanisms to improving clinical coordination between primary and outpatient secondary care and the factors influencing their use.MethodsA qualitative descriptive study in three healthcare networks of the Catalan national health system. A two-stage theoretical sample was designed: in the first stage, networks with different management models were selected; in the second, primary care (n = 26) and secondary care (n = 24) doctors. Data were collected using semi-structured interviews. Final sample size was reached by saturation. A thematic content analysis was conducted, segmented by network and care level.ResultsWith few differences across networks, doctors identified similar mechanisms contributing to clinical coordination: 1) shared EMR facilitating clinical information transfer and uptake; 2) mechanisms enabling problem-solving communication and agreement on clinical approaches, which varied across networks (joint clinical case conferences, which also promote mutual knowledge and training of primary care doctors; virtual consultations through EMR and email); and 3) referral protocols and use of the telephone facilitating access to secondary care after referrals. Doctors identified organizational (insufficient time, incompatible timetables, design of mechanisms) and professional factors (knowing each other, attitude towards collaboration, concerns over misdiagnosis) that influence the use of mechanisms.DiscussionMechanisms that most contribute to clinical coordination are feedback mechanisms, that is those based on mutual adjustment, that allow doctors to exchange information and communicate. Their use might be enhanced by focusing on adequate working conditions, mechanism design and creating conditions that promote mutual knowledge and positive attitudes towards collaboration.

Analysis of Radiological Case Presentations and their Impact on Therapy and Treatment Concepts in Internal Medicine.

Purpose Evaluation of clinical impact regarding diagnostic and therapeutic changes influenced by interdisciplinary radiological case presentations. Materials and Methods Prospective evaluation of radiological-gastrointestinal clinical case conferences over a 1-year period at a tertiary care center. We documented the preparation (phase 1) and clinical case conference (phase 2) regarding their impact on the radiology report and further diagnostic work-up and therapy. Results 1067 examinations were evaluated in 69 clinical case conferences including 487 cases. We calculated a mean time of 35.8 minutes per conference with 5.1 minutes per case for preparation. During phase 1, major changes compared to the previous report were found in 1.2 % of cases, and no change was found in 91.4 % of cases. In phase 2 an additional relevant finding was found in 0.6 % of cases, while there was no major change to the reports in 99 % of cases. We recommended further radiological diagnostic workup in 9 % of cases and interventional radiological examination in 2.7 % of cases, while no change was documented in 83.2 %. Further radiological or surgical therapy was recommended in 7 % and 6.8 % of cases, respectively. There was no change in therapy in 78.5 % of cases. Conclusion The analysis of an interdisciplinary radiological case presentation in internal medicine shows that the case discussion with the radiologist results in a change in patient management in 37.3 % of cases (16.8 % diagnosis, 21.5 % therapy). Overall, interdisciplinary radiological clinical case conferences help to improve the management and quality of patient care. Our data support the broad implementation of radiological clinical case conferences. Key Points · The second opinion obtained during the preparation of a radiological case presentation does not change the written report in most cases.. · "Talking radiology" in radiological case presentations results in a significant change in patient management in over ⅓ of all cases.. · In radiological clinical case conferences an experienced radiologist can initiate diagnostic and interventional radiological methods that can be correctly implemented in therapeutic pathways.. · "Talking radiology" improves the quality of therapy and patient care.. Citation Format · Dendl L. M., Teufel A., Schleder S. et al. Analysis of Radiological Case Presentations and their Impact on Therapy and Treatment Concepts in Internal Medicine. Fortschr Röntgenstr 2017; 189: 239 - 246.

Revisiting the Biopsychosocial Formulation: Neuroscience, Social Science, and the Patient's Subjective Experience.

Psychiatric illnesses force us to confront the vexing problem of the relationship of mind, brain, and culture [1], and therefore, the practice of psychiatry occurs “at the crossroads of biomedicine, the social sciences, and the humanities” [2]. Accordingly, psychiatry has long aspired to the biopsychosocial model first outlined by Engel in his seminal paper, which he intended to preserve a more wellrounded, humanistic approach to medicine from a strictly biomedical model [3]. Engel appreciated that illness must be addressed at each of these explanatory levels. The great challenge for clinicians has been in the actual integration of these orientations in the care of the individual patient, as opposed to an eclectic accumulation of perspectives [4, 5]. In addition, there has sometimes been a tendency to emphasize the “psychosocial” as compared to the “biological” [5]. As a result, when the biopsychosocial formulation was put into practice in clinical case conferences, the three modes were often disconnected, and the biologic was sometimes reduced to a listing of the patient’s medical comorbidities and a cursory reference to inherited genetic vulnerabilities and predispositions. In recent years, however, our understanding of neurobiology has progressed considerably, to a point where it is time to substant ia l ly revise the place of biology in our biopsychosocial model. Indeed, Insel and Quiron argued that we should redefine the “foundation of psychiatry as clinical neuroscience” and that we should best consider ourselves “clinical neuroscientists” [6]. Most recently, Ross and colleagues made a compelling argument that we should substantially enhance the neuroscience education of psychiatry residents and have provided new resources for training directors to use [7]. Anticipated advances in imaging and biomarkers are likely to redefine diagnosis, and future psychiatrists need to be ready to integrate these advances into their practice [8, 9]. In order to meet these goals, psychiatry educators will need to increase the time devoted to teaching neuroscience and also change the culture of some psychiatry departments to include an embrace of neuroscience education by psychiatric clinicians. As exciting as the possibility of personalized medicine rooted in neuroscience may be, the findings of recent neuroscience research should also prompt us to revisit the biopsychosocial model to examine the possibility of a more convergent and integrated use of the model. Indeed, recent neuroscience research repeatedly demonstrates the centrality of the social environment in brain development, and how this environment is subjectively experienced, as a significant cause of serious mental illness. This in turn has implications for the scope of the evidence base that we teach our residents—in particular highlighting those areas of the social sciences that explore the nature of childhood trauma and deprivation, its cultural and social risk factors, the subsequent stigma surrounding its sequelae, and the ways these experiences are internalized. Accordingly, this essay will explore how psychiatry residency educators might integrate selected elements of recent neurobiology and recent social science research with a focus on the patient’s subjective psychology, in the service of demonstrat ing and teaching a substantial ly enriched biopsychosocial model. This goal is consistent with the aspirations expressed in the recently established Psychiatry Milestones of the Accreditation Council for Graduate Medical Education (ACGME) that serve as a guiding framework for the progression of psychiatry residents’ educational * Adam M. Brenner adam.brenner@utsouthwestern.edu

Public Health and Preventive Medicine Meet Integrative Health: Applications of Competency Mapping to Curriculum Education at the University of Michigan.

The University of Michigan School of Public Health Preventive Medicine Residency (UMSPH PMR) Integrative Medicine Program (IMP) was developed to incorporate integrative medicine (IM), public health, and preventive medicine principles into a comprehensive curriculum for preventive medicine residents and faculty. The objectives of this project were to (1) increase the preventive medicine workforce skill sets based in complementary and alternative medicine and IM that would address individual and population health issues; (2) address the increasing demand for evidence-based IM by training physicians to implement cost-effective primary and secondary prevention services and programs; and (3) share lessons learned, curriculum evaluations, and best practices with the larger cohort of funded IM PMR programs. The UMSPH PMR collaborated with University of Michigan IM faculty to incorporate existing IM competencies with those already established for preventive medicine and public health residency training as the first critical step for IMP curriculum integration. Essential teaching strategies incorporated didactic and practicum methods, and made use of seasoned IM faculty, along with newly minted preventive medicine integrative teaching faculty, and PMR resident learners as IM teachers. The major components of the IMP curriculum included resident participation in IMP Orientation Sessions, resident leadership in epidemiology graduate IM seminars, resident rotations in IM month-long clinical practicums, resident participation in interprofessional health system-wide IM clinical case conferences, and PMR faculty enrollment in the renowned Faculty Scholars Program in Integrative Healthcare. This paper describes the novel interdisciplinary collaborations and key curriculum components that resulted in the IMP, as well as evaluation of strengths, weaknesses, and lessons learned.

Citing conduct, individualizing symptoms: Accomplishing autism diagnosis in clinical case conferences

In this paper, I examine how clinicians at a clinic for developmental disabilities in the United States determine whether children being evaluated for autism spectrum disorder (ASD) showed symptoms of that condition. Drawing on a convenience sample of 61 audio and video recorded case conferences from two time periods (1985 and 2011–15), and combining Conversation Analysis with insights from Actor Network Theory, I find that clinicians describe (via a representational practice called “citation”) children's conduct in ways that advance diagnostic claims. More specifically, they portray key actants in the assessment process in patterned ways: the test instrument is represented as a neutral tool of measurement, the clinician as administrator and instructor; and the child as the focal figure whose conduct is made to appear independent of the other participants and suggestive of diagnostic symptoms. These tacit representational conventions conform to and reproduce the assumptions of standardized testing, according to which clinicians and tests are to be neutral arbiters of the child's abilities, and thereby provide for objective, warrantable findings. At the same time, however, by designing representations around the child's symptomatic conduct in this way, clinicians may minimize or elide their own contributions, and those of the test instrument, to the child's performance, and thereby make the child alone appear responsible for what are, in fact, interactionally-occasioned behaviors.

APA's Education Council Issues Report on Need for Integrated Care Training

APA's Education Council Issues Report on Need for Integrated Care Training

Describing a residency program developed for newly graduated nurse practitioners employed in retail health settings.

Retail health clinics are an expanding health care delivery model and an emerging new practice site for nurse practitioners (NPs). Critical thinking skills, clinical competence, interprofessional collaboration, and business savvy are necessary for successful practice in this highly independent and autonomous setting. This article describes a pilot residency partnership program aimed at supporting new graduate NP transition to practice, reducing NP turnover, and promoting academic progression. Eight new graduate NPs were recruited to the pilot and paired with experienced clinical NP preceptors for a 12-month program that focused on increasing clinical and business competence in the retail health setting. The residency program utilized technology to facilitate case conferences and targeted Webinars to enhance learning and peer-to-peer sharing and support. An on-line doctoral-level academic course that focused on interprofessional collaboration in health care, population health, and business concepts was offered. Both NPs and preceptors were highly satisfied with the academic-service residency program between MinuteClinic and Northeastern University School of Nursing in Boston, MA. New NPs particularly valued the preceptor model, the clinical case conferences, and business Webinars. Because their priority was in gaining clinical experience and learning the business acumen relevant to managing the processes of care, they did not feel ready for the doctoral course and would have preferred to take later in their practice. The preceptors valued the academic course and felt that it enhanced their precepting and leadership skills. At the time of this article, 6 months post completion of the residency program, there has been no turnover. Our experience supports the benefits for residency programs for newly graduated NPs in retail settings. The model of partnering with academia by offering a course within a service organization's educational programs can enable academic progression.

Residents’ Journal: An Opportunity to Get Involved

<i>Residents’ Journal</i>: An Opportunity to Get Involved

Introduction to the 80th Anniversary Issue

With this issue, Digestive Diseases and Sciences enters its 80th year of continuous publication. To commemorate this auspicious event, we have designed the cover to resemble that of the first issue and we have added a special section, edited by our associate editor David Rubin, that provides scholarly commentaries addressing the impact of articles published in the first volumes of this journal’s predecessor, the American Journal of Digestive Diseases and Nutrition, accompanied by facsimiles of their first pages. I am also pleased to announce that DDS has expanded the scope of its reporting of academic clinical conferences to the University of New Mexico, which, under the guidance and leadership of editorial board member Denis McCarthy and our deputy editor, Henry Lin, has made available the first of a series entitled ‘‘UNM Clinical Case Conferences,’’ which will be combined with the Stanford Multidisciplinary Seminars under the rubric ‘‘DDS Distinguished Digestive Seminars.’’ The editors and editorial board of DDS are proud to have reached this point in the journal’s history. We look forward to further restoring the journal to its former preeminence as a publisher of first-quality basic and clinical science articles. We hope that the articles that we publish now will have, 80 years hence, substantially impacted the practice of medicine. We at DDS all hope that you will enjoy reading and will benefit from the special content provided in this issue in addition to our regularly published articles.

Navigating a Successful Course Through GI Fellowship: A Year-by-Year Perspective

The sense of accomplishment you felt as a resident newly-matched into your chosen field of gastroenterology gradually morphs into a combination of excitement, anticipation, and indeed a healthy amount of trepidation, as you inch closer to the start of your fellowship. But fear not. While fellowship is no doubt a character-building experience, presenting unique challenges, it can be effectively navigated with a deliberate approach. This article is intended to serve as a roadmap to guide you in successfully completing your gastroenterology fellowship.