Clinical Confidence Research Articles

Learning to Listen.

I felt a small thrill looking at the rows of short, starched coats beside me. “Keep your white coat thin so patients' stories may touch you,” instructed our welcome to medical school speaker. It was a thoughtful sentiment, but not one that particularly resonated with me at the time.And so, I progressed. From preclinical, to clinical, to residency training, I examined, prescribed, and sutured. But mostly, I listened. Increasingly, the symptoms and how they fit into diagnostic and treatment flow charts clicked neatly into place. Each specialty had its bread-and-butter complaints. My efficiency improved alongside my clinical confidence. And, I admit, the stories became more opaque. The person behind the pelvic pain in a 20-minute patient visit became quieter. I needed to collect information and focus so that I could triage, diagnose, and implement. I began practicing with an agenda, one that was well-intentioned, borne from time constraints. Lost in what was becoming routine, I slowly drifted away from the patient's experience.Then I had a patient with a surgical complication. An expected one, one specified in the consent form. But it haunted me. She haunted me. Weeks turned to months, and I found myself still waking early, thinking about her. As my husband dozed on next to me, I wondered what it might be like to manage spreadsheets rather than organs. I thought a lot about harm, consent, the risks of surgery. And about surgical training. About the lights so bright in the OR. About the attending who snapped when I wasn't prepping the patient quickly enough. About when I was frozen holding a foley, focused on managing an overwhelming panic about complications that could happen. I thought about the patient's tattoos, the small talk we had made before starting the case. Each time in the OR I wondered when I might harm. I did harm.How do you face yourself in the mirror when you know you have harmed someone? Can I trust myself again? Can others trust me? The next time I performed that same surgery, I pretended that the complication had never happened. Afterward I went to a call room and laid my head against the door, and closed my eyes. I obsessed over her postoperative course, hovering over vitals and hemoglobins.I became hypervigilant. I listened with renewed intensity, eager to not miss problems, eager to fix. I operated with fresh eyes and practiced more. I took more time with my patients and learned more about them. I thought more about how symptoms affected their lives. I thought more about how a surgery recovery would affect their work schedules. I thought about trying to breastfeed with incisions.Months later, I was working alone one weekend. The census was high and I was stretched thin. A girl on our list had a one-liner that was hard to forget. Her suffering and long-term ramifications were devastating. My role in her care was limited: I did not participate in her surgeries or manage her course. I knew her story, but I did not know her. Yet I found myself thinking of her while tucking into a dessert of toasted sweet meringue on a bed of tart raspberry purée. There was something so delightful, playful, frivolous even, about this dessert. It was the kind of thing any child would love. It felt so indulgent to be allowed this kind of joy that typifies youth. I thought, she should be playing and enjoying this kind of dessert.Driving through the forest that night, I was mesmerized by the tall pines, each perfectly coated with fresh snow. Drawn into wonder and natural beauty, I again thought of her and wondered, did my white coat get too thin?Then I became the patient in the gown. I fit perfectly into the little treatment flow chart boxes. Each step of care was medically and biologically sound, but my outcome also was not as expected. I would have made the same decisions as the clinician.There was no particular “ah-ha” moment for me. I started listening in earnest. Even in compressed patient time slots, I made room for patients to tell me how and why, not driven by fear now. The nuances of decision-making and counseling gradually gave more meaning to doctoring. I thought about patients and how my sense of responsibility and duty in medicine was tempered by factors outside of my control. I thought about patients, like myself, that do not respond as expected. About the progression of disease we believe should have responded or the cure we didn't predict. There is so much weight for us to hold. Now as I don my full-length white coat, I hope to keep it thin.

Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes.

e24003 Background: Several clinician training interventions that address serious illness communication have been developed over the past decade. While numerous studies report the impact on clinician attitude, confidence and intention to change practice, less is reported on individual education modalities and their impact on actual behavior change and patient outcomes. This study's aim was to examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes. Methods: A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted of studies that specifically measured clinician behaviors or patient outcomes. Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011, and November 2021. Results: The search identified 1132 articles: 60 met inclusion criteria describing 49 unique interventions. Common education modalities used were a single workshop (n = 18), multiple workshops (n = 8), single workshop with coaching (n = 7), multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While studies reporting behavior changes or improved patient outcomes did not confirm improvements in skills. As multiple modalities were commonly used and often embedded within larger quality improvement initiatives, the impact of individual modalities could not be determined. Conclusions: To advance the evidence of the benefits of serious illness communication training, well-defined education modalities and consistent outcome measures for behavior change and patient outcomes are needed.

HR+/HER2- Breast cancer: The effect of online education on clinician knowledge, competence, and confidence in monitoring, mitigating toxicities, and developing patient-centric plans using a team-based approach.

e12522 Background: CDK4/6 inhibitors provide effective treatment options for patients with HR-positive, HER2-negative breast cancer (BC), but adherence and persistence can be challenging. To address this gap, a global educational activity was developed that consisted of a 2-hour live streaming virtual meeting with interactive workshops and a 45-minute online enduring activity. The objective of this study was to assess the educational impact of the online enduring educational activity. Methods: To assess educational impact a repeated-pairs pre-/post-assessment study design using 3 knowledge/competence questions, in which everyone served as their own control. A paired samples t-test assessed mean differences in average number of correct responses pre- to post-assessment, and a McNemar’s test assessed significance of improvement in single questions from pre- to post-assessment. P values < .05 are statistically significant. Confidence was also assessed using a pre/post confidence question. The activity launched on June 4, 2021, and data was collected till March 30, 2022. Results: 80 oncologists from outside the US (OUS) and 69 oncologists from the US who answered all the assessment questions were included in the analysis. Each question assessed a learning objective. All three knowledge/competence learning objectives showed a significant improvement in the OUS oncologist group, and 2 of the 3 showed a significant improvement in the US group. Conclusions: This online enduring activity resulted in a significant improvement of oncologists’ knowledge and competence related to clinical evidence for the use of CDK4/6i, managing adverse events associated with CDK4/6i and monitoring patients on CDK4/6i. Confidence of oncologists in counselling patients on the importance of adherence to CDK 4/6 inhibitor therapy also improved in 29% of OUS oncologists and 33% of US oncologists. However, there is still a need for education in a significant percentage of both OUS and US oncologists on this topic. [Table: see text]

Clinician-patient insights and alignment on urothelial carcinoma care.

e18755 Background: The expansion of the treatment landscape for urothelial carcinoma (UC) including immune checkpoint inhibitors and antibody-drug conjugates (ADCs) hold the promise of improving long-term survival in patients with more advanced disease. A tethered (patient-clinician) educational initiative was designed for patients/caregivers to stay up-to-date with new therapies and for clinicians to facilitate integration of new therapies into clinical practice. Methods: Two, 1-hour online, interactive, video-based programs were designed for patients and clinicians. The patient/caregiver program was hosted on CancerCoachLive in January, 2022 and the clinician program on UroCareLive and OMedLive in December, 2022. The initiative was conducted in collaboration with LUGPA, Large Urology Group Practice Association and BCAN, Bladder Cancer Advocacy Network. Behavioral assessment of preferences and attitudes toward managing patients were examined throughout the CME series and patient/caregiver program. A planned analysis of the data from these questions determined patient and clinical impact. Outcomes from the patient program were analyzed and presented during the CME series followed by expert-identified strategies to improve clinical practice. Results: A total of 1,071 participants have engaged across both educational programs. The majority of the patient participants were in remission or had recurrent UC. Patients provided insight on what mattered most at the point of decision-making (48%), the symptoms that led to a diagnosis – hematuria (85%), and their greatest quality-of-life challenge – urinary functioning concerns (52%). Of those who have been treated previously, 83% were treated with an immunotherapy and 9% with an antibody drug-conjugate. Pre- to post-activity comparisons demonstrate a greater likelihood of participation in clinical trials. When asked about the challenges patients with UC face, the top 3 challenges identified by patients were not aligned with those identified by clinicians. Clinicians additionally identified themselves as lacking confidence (58%) in their understanding of patient’s concerns or challenges. Following the activity, clinicians were very motivated to address these concerns (88%). Clinicians identified enfortumab vedotin (44%) as the ADC with the greatest potential to improve patient outcomes and a lack of knowledge on evidence-based strategies as the primary barrier to implementing changes in practice (34%). Qualitative data from both the patient and clinician activities were captured representing write-in examples of behavioral impact which will be shared. Conclusions: The initiative contributed to the provision of valuable patient insights, patient-clinician misalignment, and clinician confidence addressing patient concerns. Increasing this awareness fostered practical strategies and discussion to improve patient-centered care.

Challenges and strategies to improve the provision of end-of-life cancer care in rural and regional communities: Perspectives from Australian rural health professionals.

To identify challenges and strategies to improve the provision of end-of-life (EOL) cancer care in an underserved rural and regional Australian local health district (LHD) from the perspective of general practitioners (GPs) and specialist clinicians while exploring the benefits of adopting a generalist health care approach to delivering EOL care in rural and regional communities. Rural and regional Australia. General practitioners and palliative care and cancer care specialists (medical and nursing) involved in the provision of EOL care to people with advanced cancer in the rural and regional areas of an Australian LHD. Qualitative descriptive study involving 22 participants in four face-to-face and online focus groups. Thematic analysis of the transcripts identified key issues affecting EOL care for people with advanced cancer in rural and regional areas of the LHD. Four themes including geographical remoteness, system structures, medical management and expertise and training emerged from the focus groups. Key barriers to effective EOL care included insufficient remuneration for GPs and other clinicians (especially home visits), resource limitations, limited community awareness of palliative care and lack of confidence and training of clinicians. Continuity of care was identified as an important facilitator to effective EOL care. Participants suggested greater Medicare rebates for palliative care and home visits, adequate equipment and resources, technology-enabled clinician training and greater rural-based training for specialist PC clinicians may improve the provision of EOL care in regional and rural communities. Rural-based clinicians delivering EOL cancer care appear to be disproportionately affected by geographical challenges including resource and funding limitations. A multi-pronged strategy aimed at greater interdisciplinary collaboration, community awareness and greater resourcing and funding could help to improve the provision of EOL care in underserved rural and remote communities of Australia.

Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review.

Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.

The effect of COVID-19 pandemic on respiratory therapy students’ clinical practice: a cross-sectional study

BackgroundDue to the 2019 Coronavirus disease (COVID-19) precaution, educational systems and learners’ practices from all specialties have been negatively affected, especially university students. COVID-19 has a massive effect on the practice of allied health students. The students’ hospital exposure has been severely affected by the cancelation of the clinical practice. This study aims to investigate the effect of COVID-19 pandemic on the clinical practice of respiratory therapy students in different universities around Jeddah, Saudi Arabia.MethodsAnalytical cross-sectional online questionnaire was distributed from August 2021 to November 2021 to respiratory therapy students. The study’s sampling technique was non-probability consecutive, and the calculated sample size was 183 participants. The survey contained questions to identify the clinical exposure of the participants. The participants included RT students in their clinical training years from King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz University, and Batterjee Medical College in Jeddah. The survey evaluated the effects of the pandemic on students’ clinical practice, confidence and clinical preparation, and education.ResultsA total of 187 respiratory therapy students completed the questionnaire. The results revealed that 145 (77.5%) of respiratory therapy students agreed that the pandemic had disrupted their clinical practice. The percentage of respiratory therapy students who felt that they were less confident and less prepared for the next academic year due to practical session cancellation was 141 (75.4%). Out of the total students, 135 (72.2%) students reported difficulty in connecting the clinical and theoretical part because of the pandemic.ConclusionThe majority of respiratory therapy students from the three universities similarly reported that the pandemic disrupted their practice and interfered with their ability to connect between clinical and theoretical part. Moreover, it had affected their confidence and preparedness for the next year.

(019) Longitudinal Observation on the Prevalence and Impact of Psychological Distress Among Patients Treated for Erectile Dysfunction During the COVID Pandemic

Abstract Introduction The COVID global pandemic has significantly affected the delivery of the healthcare system with valued resources diverted to cope with more urgent clinical services. Erectile dysfunction (ED) is considered a non-urgent medical condition and hence, males with ED were not prioritised and invariably faced long delays in clinical management including postponement in surgical waitlist during this pandemic. Objective To assess the prevalence and impact of psychological distress among males with ED during the COVID pandemic based on changes in the outcomes of validated questionnaires such as the International Index of Erectile Function (IIEF), Depression and Anxiety Stress Scales (DASS-21), Sexual Distress Scale (SDS) and Decisional Engagement Scale (DES-10), as well as perceived availability of medical support. Methods Following ethics approval, this prospective longitudinal study tracked males with ED at a tertiary medical centre between June 2020 and June 2022. Inclusion criteria included males aged 20 to 70 years, who have pre-existing ED (greater than 6 months), receiving medical therapies for ED, and had enrolled in the prospective database at the time of the study. Exclusion criteria were those who have undergone penile prosthesis implantation or received major abdominopelvic surgery during the study period that may preclude sexual activity. All patients completed validated questionnaires at 0, 6, 12, 18 and 24 months with additional data collected during the peak periods of local COVID social measure lockdown. Results A total of 80 patients were identified during the 24 months and 20 patients dropped out due to surgery (15 patients) and incomplete follow-up (5 patients). The mean age of males was 46.8 (21-69) years, and the duration of ED was 14.5 (6-33) months. Almost one-third of the patients showed increased DASS scores on depression (38 patients) and anxiety (42 patients) subscales and one-quarter on stress (29 patients) subscales, with worse DASS scores during the peak periods of social measures. On the SDS questionnaire, higher concerns were registered across all domains apart from the question on regrets about your sexuality. The analyses showed a worsening of the IIEF scores (p<0.021), anxiety and stress (DASS score with p=0.045 and p=0.038, respectively) as well as SDS score (p=0.048) during this pandemic. However, the DES-10 scores were more positive with most patients reporting a score above 7 out of 10 in terms of items on accepting current arrangement (75%) and confidence in clinician decision-making about the treatment (80%) although most patients (92%) indicated the desire to be kept updated and provided with more detailed information on their clinical care. Conclusions The COVID pandemic has caused an adverse psychosexual impact on many patients’ erectile function and mental well-being, and social measures lockdown invariably heightened patient psychosexual distress. Our study showed regular clinical contact and medical reassurance coupled with an explanation of reasons for clinical delays in the non-urgent medical condition resulted in a high level of confidence in clinicians and potentially minimised emotional adjustment in the patients. Disclosure No

In silico development and validation of Bayesian methods for optimizing deep brain stimulation to enhance cognitive control

Objective. deep brain stimulation (DBS) of the ventral internal capsule/striatum (VCVS) is a potentially effective treatment for several mental health disorders when conventional therapeutics fail. Its effectiveness, however, depends on correct programming to engage VCVS sub-circuits. VCVS programming is currently an iterative, time-consuming process, with weeks between setting changes and reliance on noisy, subjective self-reports. An objective measure of circuit engagement might allow individual settings to be tested in seconds to minutes, reducing the time to response and increasing patient and clinician confidence in the chosen settings. Here, we present an approach to measuring and optimizing that circuit engagement. Approach. we leverage prior results showing that effective VCVS DBS engages cognitive control circuitry and improves performance on the multi-source interference task, that this engagement depends primarily on which contact(s) are activated, and that circuit engagement can be tracked through a state space modeling framework. We develop a simulation framework based on those empirical results, then combine this framework with an adaptive optimizer to simulate a principled exploration of electrode contacts and identify the contacts that maximally improve cognitive control. We explore multiple optimization options (algorithms, number of inputs, speed of stimulation parameter changes) and compare them on problems of varying difficulty. Main results. we show that an upper confidence bound algorithm outperforms other optimizers, with roughly 80% probability of convergence to a global optimum when used in a majority-vote ensemble. Significance. we show that the optimization can converge even with lag between stimulation and effect, and that a complete optimization can be done in a clinically feasible timespan (a few hours). Further, the approach requires no specialized recording or imaging hardware, and thus could be a scalable path to expand the use of DBS in psychiatric and other non-motor applications.

Initial report on special operations clinical training at a civilian academic medical center.

Military-civilian partnerships for combat casualty care skills training have mostly focused on traditional, combat surgical team training. We sought to better understand US Special Forces (SF) Medics' training at West Virginia University in Morgantown, West Virginia, a Level 1 trauma center, via assessments of medical knowledge, clinical skills confidence, and technical performance. Special Forces Medics were evaluated using posttraining medical knowledge tests, procedural skills confidence surveys (using a 5-point Likert scale), and technical skills assessments using fresh perfused cadavers in a simulated combat casualty care environment. Data from these tests, surveys, and assessments were analyzed for 18 consecutive SF medic rotations from the calendar years 2019 through 2021. A total of 108 SF Medics' tests, surveys, and assessments were reviewed. These SF Medics had an average of 5.3 years of active military service; however, deployed experience was minimal (73% never deployed). Review of knowledge testing demonstrated a slight increase in mean test score between the precourse (80% ± 14%; range, 50-100%) when compared with the postcourse (82% ± 14%; range, 50-100%). Skills confidence scores increased between courses, specifically within the point of injury care ( p = 0.09) and prolonged field care ( p < 0.001). Technical skills assessments included cricothyroidotomy, chest tube insertion, and tourniquet placement. This study provides preliminary evidence supporting military-civilian partnerships at an academic Level 1 trauma center to provide specialty training to SF Medics as demonstrated by increase in medical knowledge and confidence in procedural skills. Additional opportunities exist for the development technical skills assessments. Therapeutic/Care Management; Level IV.

Clinical competence, satisfaction, and confidence of prelicensure nursing students following video prebriefing in a women's health simulation

The purpose of this study was to examine the effects of video prebriefing with expert modeling on prelicensure student nurses' clinical competency, self-confidence, and satisfaction with learning in simulation. Expert modeling videos were shown to intervention groups before simulation compared to groups receiving standard prebriefing. Students who received video prebriefing reported increased self-confidence compared to those who received standard prebriefing. No significant difference existed in clinical competency between groups.

Online CME Effectively Improves Obstetrician–Gynecologists' Clinical Knowledge and Confidence Related to Cytomegalovirus [ID: 1368765

INTRODUCTION: We sought to determine whether an online continuing medical education (CME) series could improve the clinical knowledge and confidence of obstetrician–gynecologists related to cytomegalovirus (CMV). METHODS: Two online, 30-minute panel discussions, with educational effects assessed for matched learners completing all pre/post questions. The McNemar's test assessed differences from pre to post (P&lt;.05 are statistically significant). The activities launched in March and April 2022, and data were collected for 3 months for each activity. RESULTS: Overall, 50–51% of obstetrician–gynecologists demonstrated improvements. For activity 1 (N=147), 31% improved at recognizing the burden of CMV (P&lt;.01, 44% need additional education); 20% improved at selecting CMV acquisition risk reduction strategies (P&lt;.01, 25% need additional education); 24% improved at identifying complications of congenital CMV (P&lt;.01, 26% need additional education); 51% increased confidence at educating pregnant women about CMV risk reduction (P&lt;.01), with an average confidence shift of +78% among those who improved. For activity 2 (N=130), 32% improved at recognizing the lifecycle of CMV (P&lt;.01, 32% need additional education); 24% improved at selecting factors associated with CMV seropositivity (P&lt;.01, 35% need additional education); 15% improved at identifying common complications of CMV at birth (P&lt;.01, 35% need additional education); 48% increased confidence at understanding of the role of CMV serostatus in pregnant patients (P&lt;.01), with an average confidence shift of +79% among those who improved. CONCLUSION: This study demonstrates the success of an online, serial learning initiative at improving clinical knowledge and confidence of obstetrician–gynecologists related to CMV. Continued gaps were identified for future education.

Clinicians’ Views on Eye Movement Desensitization and Reprocessing Therapy: A Mixed Method Systematic Review

This mixed methods systematic review aimed to provide insight into the clinicians’ views and experiences of eye movement desensitization and reprocessing (EMDR). Seven electronic databases (PsychINFO, Public MEDLINE [PubMed], Cumulated Index to Nursing and Allied Health Literature [CINAHL], Scopus, Web of Science and Excerpta Medica Database [EMBASE], and Applied Social Sciences Index) and grey literature (ProQuest and Google Scholar) were searched systematically from inception to October 2021. Quality was assessed using the Mixed Methods Appraisal Tool and a convergent integrated approach was used to synthesize and integrate the data. In total, 14 studies were included: 7 qualitative, 5 mixed methods, and 2 quantitative, encompassing 1,065 participants. Thematic synthesis generated two overarching themes and seven subthemes. The first theme related to the facilitators and barriers clinicians experience in adopting and implementing EMDR, including the role of organizational support, clinician confidence, primary theoretical orientation, and client suitability and preparedness. The second theme related to the perceived advantages of EMDR, including rapid results and positive outcomes, client empowerment, and getting to the root of the issue. This review provides a helpful insight into the factors that influence the dissemination and implementation of psychological therapeutic approaches.

The impact of a cognitive impairment support program on patients in an acute care setting: a pre-test post-test intervention study

BackgroundPatients with cognitive impairment are at greater risk of hospital acquired complications, longer hospital stays, and poor health outcomes compared to patients without cognitive impairment. The Cognitive Impairment Support Program is a multi-disciplinary approach to improve screening rates and awareness of patients with cognitive impairment and guide clinician response and communication during their hospitalisation to improve health outcomes.ObjectiveThis study evaluated the impact of implementing the Cognitive Impairment Support Program on patient hospital acquired complications, patient reported quality of life and staff satisfaction in an outer metropolitan hospital.DesignA pre-test post-test design was used to collect data in two 6-month time periods between March 2020 and November 2021.ParticipantsPatients aged ≥ 65 years, admitted to a participating ward for > 24 h.InterventionThe Cognitive Impairment Support Program consisted of four components: cognitive impairment screening, initiation of a Cognitive Impairment Care Plan, use of a Cognitive Impairment Identifier and associated staff education.MeasuresThe primary outcome was hospital acquired complications experienced by patients with cognitive impairment identified using clinical coding data. Secondary outcomes were patient quality of life and a staff confidence and perceived organisational support to care for patients with cognitive impairment.ResultsHospital acquired complication rates did not vary significantly between the two data collection periods for patients experiencing cognitive impairment with a 0.2% (95% confidence interval: -5.7–6.1%) reduction in admissions with at least one hospital acquired complication. Patients in the post intervention period demonstrated statistically significant improvements in many items in two of the Dementia Quality of Life Measure domains: memory and everyday life. The staff survey indicated statistically significant improvement in clinical staff confidence to care for patients with cognitive impairment (p = 0.003), satisfaction with organisational support for patients (p = 0.004) and job satisfaction (p ≤ 0.001).ConclusionThis study provides evidence that a multicomponent Cognitive Impairment Support Program had a positive impact on staff confidence and satisfaction and patient quality of life. Broader implementation with further evaluation of the multicomponent cognitive impairment intervention across a range of settings using varied patient outcomes is recommended.

Point-of-care measurement of C-reactive protein promotes de-escalation of treatment decisions and strengthens the perceived clinical confidence of physicians in out-of-hours outpatient emergency medical services

ObjectivesOut-of-hours outpatient emergency medical services (OEMS) provide healthcare for patients with non-life-threatening conditions in need for urgent care when outpatient practices are closed. We studied the use of point-of-care-testing of...

COVID-19 vaccination telephone outreach: an analysis of the medical student experience

ABSTRACT Introduction The COVID-19 pandemic diminished opportunities for medical students to gain clinical confidence and the ability to contribute to patient care. Our study sought out to understand the value of telephone outreach to schedule COVID-19 vaccines on medical student education. Materials and Methods Forty students engaged in telephone outreach targeting patients aged 65+ without active patient portals to schedule COVID-19 vaccines. Data consisted of a single administration retrospective pre/post survey inquiring about what students learned, expectations, other health-care processes that would benefit from outreach, and interest in a population health elective. Likert items were analyzed and open response analysis involved inductive coding and generation of thematic summaries by condensing codes into broader themes. Demographic data of patients called and subsequently received the vaccine were also collected. Results There were 33 survery respondents. There was a statistically significant increase in net comfortability for pre-clerkship students for documenting in Epic, providing telehealth care, counseling on common health-care myths, having challenging conversations, cold-calling patients, and developing an initial trusting relationship with patients. The majority called and who received the vaccine were non-Hispanic Black, within the high SVI category, and had Medicare and/or Medicaid. Qualitative data showed that students emphasized communication, the role of trusted messengers, the need to be open minded, and meeting patients where they are. Discussion Engaging students in telephone outreach early in the COVID-19 pandemic provided students the opportunity to develop their skills as physicians-in-training, contribute to combating the ongoing pandemic, and add value to the primary care team. This experience allowed students to practice patience, empathy, and vulnerability to understand why patients had not received the COVID-19 vaccine; this was an invaluable experience that helped students develop the skills to become empathetic and caring physicians, and supports the continued role of telehealth in future medical school curriculum.

Peripheral artery disease (PAD) in primary care-educational experiences for PAD primary care in England-a mixed-method study.

Peripheral artery disease (PAD), the pathophysiologic narrowing of arterial blood vessels of the lower leg due to atherosclerosis, is a highly prevalent disease, with sharp increases in prevalence with age. Primary care is ideally located to identify and manage PAD. This study aims to identify the educational experiences, opinions, and confidence of primary care clinicians (PCCs) regarding PAD. This mixed-method study was conducted within primary care in England. An online survey was completed with follow-on semistructured interviews, between January and September 2021, with PCCs, namely GPs, practice nurses, and allied professionals (survey n = 874, interviews n = 50). PCCs report variation in PAD education received, where the content could not often be recalled. Patient-focussed experiential and self-directed learning, formed the largest method to gain PAD education. All PCCs recognized that they have an important role in recognizing PAD yet confidence in recognizing and diagnosing PAD was lacking. PCCs acknowledged that late or missed PAD diagnosis resulted in significant patient morbidity and mortality. Yet many did not recognize PAD as a common disease. As "specialist-generalists" with finite resources, education provided to primary care needs to be applicable for the multimorbid patient presentations often seen, utilizing resources available in primary care, with consideration to the time constraints endured.

Management of reirradiations: A clinical and technical overview based on a French survey

IntroductionThe reirradiation number increased due to systemic therapies and patient survival. Few guidelines regarding acceptable cumulative doses to organs at risk (OARs) and appropriate dose accumulation tools need, made reirradiation challenging. The survey objective was to present the French current technical and clinical practices in reirradiations. MethodsA group of physician and physicists developed a survey gathering major issues of the topic. The questionnaire consisted in 4 parts: data collection, demographic, clinical and technical aspects. It was delivered through the SFRO and the SFPM. Data collection lasted 2 months and were gathered to compute statistical analysis. Results48 institutions answered the survey. Difficulties about patient data collection were related to patient safety, administrative and technical limitations. Half of the institutions discussed reirradiation cases during a multidisciplinary meeting. It mainly aimed at discussing the indication and the new treatment total dose (92%). 79% of the respondents used various references but only 6% of them were specific to reirradiations. Patients with pain and clinical deficit were ranked as best inclusion criteria. 54.2% of the institutions considered OARs recovery, especially for spinal cord and brainstem. A commercial software was used for dose accumulation for 52% of respondents. Almost all institutions performed equivalent dose conversion (94%). A quarter of the institutions estimated not to have the appropriate equipment for reirradiation. ConclusionThis survey showed the various approaches and tools used in reirradiation management. It highlighted issues in collecting data, and the guidelines necessity for safe practices, to increase clinicians confidence in retreating patients.

How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review

BackgroundAdvance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals’ care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this.MethodsMixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000–04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients’ care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough’s Weight of Evidence.ResultsN=35papers were included in total; all had Medium/High Weight of Evidence. Fifteenpapers (comparing two or more ethnic groups) addressed the primary outcomemeasure. Twelve of the fifteen papers reported White patients had statisticallyhigher rates of formally documented ACP in their care records than patientsfrom other ethnic groups. There were no significant differences in the presenceof informal ACP between ethnic groups. Nineteen papers addressed the secondaryoutcome measure; thirteen discussed patient-based factors impacting ACPpresence with four key themes: poor awareness and understanding of ACP; financialconstraints; faith and religion; and family involvement. Eight papers discussedclinician-based factors with three key themes: poor clinician confidence aroundcultural values and ideals; exacerbation of institutional constraints; andpre-conceived ideas of patients’ wishes.ConclusionsThis review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences.Trial registrationPROSPERO-CRD42022315252.

Screening and Brief Interventions for Alcohol Use During Pregnancy: Practices Among US Primary Care Clinicians, DocStyles 2019.

Alcohol use during pregnancy can cause birth defects and developmental disabilities. From 2018 through 2020, 13.5% of pregnant women reported current drinking. The US Preventive Services Task Force recommends evidence-based tools (eg, AUDIT-C and SASQ) for implementing screening and brief interventions to reduce excessive alcohol use among adults, including pregnant people, for whom any alcohol use is considered excessive. We used DocStyles 2019 data to conduct a cross-sectional analysis to examine current screening and brief intervention practices that primary care clinicians conduct among pregnant patients; clinicians' confidence levels in conducting screening, brief interventions, and referral to treatment; and the documentation of brief interventions in the medical record. A total of 1,500 US adult medicine clinicians completed the entire survey. Among the respondents who conduct screening (N = 1,373) and brief interventions (N = 1,357) in their practice, nearly all reported implementing screening (94.6%) and brief interventions (94.9%) with their pregnant patients for alcohol use, but fewer than half felt confident about conducting their screening practices (46.5%). Two-thirds (64%) reported using a tool that met the criteria recommended by the US Preventive Services Task Force (USPSTF). Over half documented brief interventions in electronic health record notes (51.7%) or designated space (50.7%). Pregnancy presents a unique opportunity for clinicians to incorporate screening into routine obstetric care and encourage behavior change among patients. Most providers reported always screening their pregnant patients for alcohol use, but fewer used evidence-based USPSTF-recommended screening tools. Increased clinician confidence in screening and brief intervention, the use of standardized screening tools tailored to pregnant people, and maximal use of electronic health record technology may enhance the benefits of their application to alcohol use, which ultimately can reduce adverse outcomes associated with alcohol use during pregnancy.