Clinician-related Factors Research Articles

Analysis of Timely Follow-Up in the Evaluation of Postmenopausal Bleeding

OBJECTIVE: To characterize guideline-adherent follow-up in patients evaluated with transvaginal ultrasonography (TVUS) for postmenopausal bleeding. METHODS: We conducted a retrospective study of patients with an intact uterus and postmenopausal bleeding who presented to a single academic institution and underwent TVUS between January 2013 and December 2022. Primary outcome measures were prompt follow-up, defined as receipt of endometrial sampling within 3 months of a finding of thickened or inadequately visualized endometrium, diagnosis of endometrial cancer, cancer stage at diagnosis, and rates of tissue sampling. Associations between sociodemographic variables and prompt follow-up were assessed. A Pareto analysis was performed to describe reasons for lack of prompt follow-up. RESULTS: Of 1,671 patients with thickened endometrium, 307 (18.4%) did not receive prompt follow-up; of 389 patients with inadequately visualized endometrium, 128 (33.0%) did not receive prompt follow-up. Sociodemographic variables were not associated with prompt follow-up. Clinician-related factors, including misinterpretation of ultrasound results, accounted for 46.1% of delayed or absent follow-up for thickened endometrium and 58.4% of inadequately visualized endometrium. The rates of diagnosing endometrial cancer within 1 year were similar after findings of thickened endometrium (8.8%; 95% CI, 7.5–10.3%) compared with inadequately visualized (7.7%; 95% CI, 5.3–10.9%) endometrium. CONCLUSION: Clinician misinterpretation of TVUS performed for postmenopausal bleeding was the most common reason for delayed or absent follow-up. Given observed suboptimal rates of prompt follow-up after findings of thickened or inadequately visualized endometrium on ultrasonography and similar rates of an eventual cancer diagnosis in these cohorts, efforts should be focused on clinician understanding of ultrasonographic endometrial evaluation. To simplify the diagnostic process and reduce the risk of missing a cancer diagnosis, universal endometrial sampling for patients with postmenopausal bleeding could be considered.

Bariatric surgeons' views on barriers and enablers to bariatric surgery in Australia and New Zealand: A qualitative content analysis.

Bariatric surgery can be an effective treatment for severe obesity, yet publicly-funded access is often limited. Bariatric surgeons contribute to decisions regarding consumer (non)progression to bariatric surgery. Still, little is known about their views on barriers and enablers to bariatric surgery in the Australian and New Zealand context. The current study addresses this knowledge gap. A qualitative design was utilised. Sixteen bariatric surgeons and registrars from Australia and New Zealand were interviewed about their views on barriers and enablers to bariatric surgery. The data were analysed using qualitative content analysis. Five content categories were derived from the analysis: 1. patient-related factors; 2. healthcare experiences and clinician-related factors; 3. societal beliefs and attitudes towards obesity, bariatric surgery and bariatric surgeons; 4. economic, governmental and institutional factors; and 5. bariatric surgery in the context of other treatments. A perceived lack of focus on obesity and publicly-funded bariatric surgery was apparent throughout the data in the form of descriptions of stigma, clinicians' disillusionment, patients not being guided and supported, and inadequate regulation and organisation of the field. The role of patients in determining their surgical progression was emphasised. Participants discussed numerous barriers but fewer facilitators to bariatric surgery in Australia and New Zealand. Some of their opinions merit exploration with other bariatric multi-disciplinary team members and patients to understand further how the pre-operative process might be enhanced to support patients' needs and improve equity.

Trauma clinicians’ views of physical exercise as part of PTSD and complex PTSD treatment: A qualitative study

Physical exercise has the potential to be a helpful, adjunctive intervention for supporting people with post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD). However, little is known about the views of clinicians on including physical exercise in treatment. We aimed to explore trauma clinicians’ perspectives on the role of physical exercise in PTSD and CPTSD treatment and to understand key barriers and facilitators in recommending physical exercise as an adjunctive treatment. Twelve specialist trauma clinicians from across the UK were interviewed to explore their views on the role of physical exercise and the key barriers and facilitators in recommending it as an adjunctive treatment for PTSD and CPTSD. We used a qualitative explorative methodology with semi-structured interviews and analysed transcripts using reflexive thematic analysis. Trauma clinicians viewed physical exercise as a potentially beneficial supportive intervention for PTSD and CPTSD, and perceived several ways in which physical exercise could be included in the treatment process, with an individualised approach to care underpinning inclusion. However, there were also notable barriers to including exercise at environmental, client and clinician/service levels, including; limited access to exercise resources, client-related factors such as agoraphobia and physical health problems, clinician-related factors such as lack of confidence and training, and service-level factors such as gaps in service provision. The findings highlight the importance of considering individualised approaches to physical exercise interventions in trauma treatment. Addressing identified barriers, such as improving access to resources and providing training for clinicians, is crucial for successful integration of physical exercise into PTSD and CPTSD treatment protocols. This study underscores the need for further research to inform future policies and provide guidance for trauma clinicians on how to effectively incorporate physical exercise as an adjunctive treatment.

Gender-affirming care through the lens of abnormal illness behaviour and abnormal treatment behaviour.

To describe the increasing number and changing demographics of patients presenting with gender dysphoria and provide an account of patient- and clinician-related factors which may have contributed to these changes. The concept of abnormal illness behaviours introduced by Pilowsky, and its extension to the concept of abnormal treatment behaviours by Singh, provides a framework for understanding healthy and pathological interactions between gender dysphoria patients and their doctors. Abnormal illness behaviours driven by the reinforcing contingencies of gender-affirming care may explain, in part, the increasing number and changing demographics of gender dysphoria, as well as the increasing incidence of desistance and detransition. The under-diagnosis and under-treatment of mental health disorders by clinicians treating these patients are examples of abnormal treatment behaviours. Uncritical affirmation of patient reported gender identity appears likely to conceal unconscious motivations of some patients and clinicians, increasing the risks of harm to both.

Ten misconceptions regarding decision-making in critical care

Diagnostic errors are prevalent in critical care practice and are associated with patient harm and costs for providers and the healthcare system. Patient complexity, illness severity, and the urgency in initiating proper treatment all contribute to decision-making errors. Clinician-related factors such as fatigue, cognitive overload, and inexperience further interfere with effective decision-making. Cognitive science has provided insight into the clinical decision-making process that can be used to reduce error. This evidence-based review discusses ten common misconceptions regarding critical care decision-making. By understanding how practitioners make clinical decisions and examining how errors occur, strategies may be developed and implemented to decrease errors in Decision-making and improve patient outcomes.

Influence of Clinician-Related Factors on Adherence to the American Heart Association Guidelines for Acute Coronary Syndrome among Clinicians at Kenya Ports Authority Clinics in Mombasa, Kenya

Purpose: The aim of the study was to assess influence of clinician-related factors on adherence to the American heart association guidelines for acute coronary syndrome among clinicians at Kenya Ports Authority clinics in Mombasa, Kenya. Methodology: A descriptive cross-sectional study involving quantitative methods of data collection was adopted. An interviewer administered questionnaire was used for data collection. The study was carried out in Kenya Ports Authority clinics in Mombasa, Kenya. The target population was 106 clinicians attending to patients who present with Acute Coronary Syndrome at the KPA clinics in Mombasa. A census method was used to determine the study participants. The sample size was made up of a hundred and six participants. The clinicians who consented to participate in the study were included while those who were on sick off, leave or who recently joined the clinic were excluded. Pretesting of the study tool was done at the Kenya Pipeline Clinic Mombasa. Data analysis was done using Statistical Package for Social Sciences version 25 and presented via tables. Findings: The study results showed that at 95% level of confidence (ρ-value = 0.05%), there was a significant association between gender (ᾳ=0.025), work experience (ᾳ=0.016), job cadre (ᾳ=0.014) and training received (ᾳ=0.022) on adherence to the American Heart Association Guidelines for Acute Coronary Syndrome among clinicians at Kenya Ports Authority clinics in Mombasa, Kenya. The association was insignificant between age (ᾳ=0.178), education level (ᾳ=0.439) and specialization (ᾳ=0.489) on adherence to the AHA guidelines. Unique Contribution to Theory, Practice and Policy: The study recommends that the KPA management should increase the medical budget to ensure availability of adequate resources for ACS patient management. These resources include adequate staffing, medication, equipment, and staff training costs. The clinic management should ensure that medications such as aspirin, morphine and nitroglycerine are readily available and accessible at patients care points. The KPA clinic management to formulate a simple algorithm that outlines the steps to be taken when managing ACS patients. The study recommends that the clinics should assess their equipment reqularly for maintenance controls to ensure efficiency. The study further recommends random assessments and post care audits to assess the adherence to ACS guidelines among clinicians. Training associated with adherence to the AHA guidelines and as such, KPA should continue offering training and education on the latest AHA guidelines for ACS to ensure updated guidelines for practice.

Towards an LLM based approach for medical e-consent

The question of informed and voluntary consent emerges as a matter of significance in healthcare. Obtaining informed consent, encounters many obstacles coupled with systemic, clinician-related, and patient-related factors, demanding interventions at different levels. This paper introduces a novel approach to present personalized consent based on Large Language Models (LLMs). The personalization of information is displayed through the combination of the LLM with a knowledge graph. We focus in our approach on how the knowledge graph enhances and personalize content generation, allowing therefore the acquisition of informed consent. The paper focuses as well on aspects related to hyper-parameters of information retrieval that help giving better prompt to the LLM. Experiments have showcased intresting results in terms of personalization and information retrieval using metrics of Rouge, Faithfulness and Relevance.

Factors contributing to the non-identification of bacterial meningitis in febrile infants: A case series study.

Non-identification of serious bacterial infection (SBI) in febrile infants is a common occurrence in clinical practice, culminating in catastrophic presentations. Six infants who initially presented to the clinician with fever without a focus, and were lately diagnosed with bacterial meningitis were analyzed for clinician-related factors contributing to the non-identification of meningitis. In a febrile neonate and a febrile young infant, lack of comprehensive evaluation was contributing to the non-identification of SBI; in four infants above the age of 3 months, meningitis was missed in spite of clinicians practicing treatment guidelines. Inadequate symptom characterization in two febrile infants and inappropriate interpretation of hemogram in three febrile infants also contributed to the non-identification of meningitis. Except for one, all infants developed complications. We conclude that the characterization of clinical features of SBI-like meningitis, interpretation of lab data, and adherence to the treatment guidelines are crucial in the management of an infant presenting as fever without a focus.

Clinician perspectives on nutritional impairment in children undergoing cancer chemotherapy in Thailand: A qualitative descriptive study

ObjectiveThis study aimed to explore the perspectives of pediatric oncology clinicians in Thailand on children's gastrointestinal ​symptoms, eating habits, and nutrition during cancer chemotherapy. Additionally, it sought to identify factors influencing children's nutritional status, including the characteristics of the children, clinician-related factors, and hospital-level factors. MethodsThe study involved pediatric oncology clinicians working at a tertiary hospital in Bangkok. Data were collected through interviews, focusing on three key areas: (1) children's gastrointestinal symptoms, eating behaviors, and nutrition, (2) clinicians' cognitions and behaviors that impact children's nutrition, and (3) environmental factors. Each participating clinician also identified a colleague who could offer additional perspectives. Interviews were conducted in the Thai language and analyzed using directed content analysis. ResultsA total of 22 participants were enrolled in the study, comprising sixteen nurses, four physicians, one child life specialist, and one Hospital Nutrition Service staff member. The majority of participants were female (95.4%), with an average age of 37.77 years and an average of 15.55 years of experience in caring for children with cancer. Factors influencing children's nutritional status included the children's cancer diagnosis, treatment exposures, and symptoms. Clinicians attributed changes in children's weight and eating patterns to these symptoms. Influential clinician-related factors included current practices that impacted children's symptoms and food intake. Hospital-level factors included both direct influences on children and those arising from clinical practices. ConclusionsTo optimize the nutritional status of Thai children undergoing chemotherapy, multi-level interventions are needed. These interventions should target children's symptoms, clinician knowledge, role norms, and address issues related to the hospital environment, specifically those elements that contribute to unpleasant experiences.

Factors perceived by health professionals to be barriers or facilitators to caries prevention in children: a systematic review

BackgroundConsidered the most prevalent noncommunicable disease in childhood, dental caries is both an individual and a collective burden. While international guidelines highlight prevention as a major strategy for caries management in children, health professionals still struggle to implement prevention into their clinical practice. Further research is needed to understand the gap between the theoretical significance of dental prevention and its lack of implementation in the clinical setting. This systematic review aims to identify and classify factors perceived by health professionals to be barriers or facilitators to caries prevention in children.MethodA systematic literature search was conducted in three electronic databases (Medline, Web of Science and Cairn). Two researchers independently screened titles, abstracts and texts. To be selected, studies had to focus on barriers or facilitators to caries prevention in children and include health professionals as study participants. Qualitative and quantitative studies were selected. The factors influencing caries prevention in children were sorted into 3 main categories (clinician-related factors, patient-related factors, and organizational-related factors) and then classified according to the 14 domains of the theoretical domains framework (TDF).ResultsA total of 1771 references were found by combining manual and database searches. Among them, 26 studies met the inclusion criteria, of which half were qualitative and half were quantitative studies. Dentists (n = 12), pediatricians (n = 11), nurses (n = 9), and physicians (n = 5) were the most frequently interviewed health professionals in our analysis. Barriers and facilitators to caries prevention in children were categorized into 12 TDF domains. The most frequently reported domains were Environmental Context and Resources, Knowledge and Professional Role and Identity.ConclusionThis systematic review found that a wide range of factors influence caries prevention in children. Our analysis showed that barriers to pediatric oral health promotion affect all stages of the health care system. By highlighting the incompatibility between the health care system’s organization and the implementation of caries prevention, this study aims to help researchers and policy-makers design new interventions to improve children’s access to caries prevention.Trial registrationPROSPERO CRD42022304545.

Perspectives of patients and clinicians on older patient mobility on acute medical wards: a qualitative study

BackgroundLow mobility during an acute care medical hospitalization is frequent and associated with adverse outcomes, particularly among older patients. Better understanding barriers and facilitators to improve mobility during hospitalization could help develop effective interventions. The goal of this study was to assess barriers and facilitators to older medical patients’ hospital mobility, from the point of view of patients and clinicians, to develop a framework applicable in clinical practice.MethodsWe conducted a qualitative study in one university and two non-university hospitals of two different language and cultural regions of Switzerland, including 13 focus groups (FGs; five with patients, eight with clinicians). We included 24 adults aged 60 years or older hospitalized on an acute general internal medicine ward of one of the three participating hospitals during the previous years, and 34 clinicians (15 physicians, nine nurses/nursing assistants, 10 physiotherapists) working on those wards. The FG guides included open-ended questions exploring mobility experiences, expectations, barriers and facilitators to mobility, consequences of low mobility and knowledge on mobility. We applied an inductive thematic analysis.ResultsWe identified four themes of barriers and facilitators to mobility: 1) patient-related factors; 2) clinician-related factors; 3) social interactions; and 4) non-human factors. Clinician-related factors were only mentioned in clinician FGs. Otherwise, subthemes identified from patient and clinician FGs were similar and codes broadly overlapped. Subthemes included motivation, knowledge, expectations, mental and physical state (theme 1); process, knowledge – skills, mental state – motivation (theme 2); interpersonal relationships, support (theme 3); hospital setting – organization (theme 4).ConclusionsFrom patients’ and clinicians’ perspectives, a broad spectrum of human and structural factors influences mobility of older patients hospitalized on an acute general internal medicine ward. New factors included privacy issues and role perception. Many of those factors are potentially actionable without additional staff resources. This study is a first step in participatory research to improve mobility of older medical inpatients.

Keeping clients connected: exploring Australian alcohol and other drug clinicians’ perspectives on barriers and facilitators to treatment attendance

Substance use contributes to significant individual and social harms. Although psychosocial treatment is effective, early treatment discontinuation is common. Despite this, exploration of clinicians’ perspectives on barriers and facilitators to attendance has been limited in scope (e.g. specialized settings, written responses). The current study used an in-depth approach to explore the views of clinicians on barriers and facilitators to attendance in psychosocial alcohol and other drug (AOD) treatment, with a view to translating these views to clinical practice. Semi-structured interviews were conducted with AOD clinicians from a range of professional backgrounds (n = 15: 7 female; 8 male) working in treatment settings in Australia. Thematic analysis was used to analyze interview content. Themes relating to attendance included client-related factors (motivation, expectations, beliefs; complexity, access, level of support), clinician-related factors (therapeutic relationship), organizational and systemic factors (individual service factors; systemic/sector wide factors), and stigma (experienced across clinician-related, organization and systemic domains). A complex combination of practical, psychosocial, and systemic/organizational factors intersect with, and influence, client attendance. These findings speak to the importance of client-centered and flexible approaches from clinicians and organizations. Such approaches might simultaneously mitigate a key barrier to attendance: stigma. This study highlights the impact of the therapeutic relationship on attendance despite organizational and funding constraints.

Patient, Provider, and Health Systems Factors Leading to Lumbar Puncture Nonperformance in Zambia: A Qualitative Investigation of the "Tap Gap".

Lumbar puncture (LP) and cerebrospinal fluid (CSF) diagnostics are critical for evaluating central nervous system infections but are often not conducted, resulting in the "Tap Gap." To investigate patient, provider, and health systems factors contributing to the Tap Gap in Zambia, we conducted focus group discussions with adult caregivers of hospitalized inpatients and in-depth interviews with nurses, clinicians, pharmacy workers, and laboratory staff. Transcripts were independently thematically categorized by two investigators using inductive coding. We identified seven patient-related factors: 1) alternative understandings of CSF; 2) alternative information about LPs, including misinformation; 3) mistrust of doctors; 4) consent delays; 5) fear of blame; 6) peer pressure against consent; and 7) association between LP and stigmatized conditions. Four clinician-related factors were identified: 1) limited LP knowledge and expertise, 2) time constraints, 3) delays in LP requests by clinicians, and 4) fear of blame for bad outcomes. Finally, five health systems-related factors were identified: 1) supply shortages, 2) constrained access to neuroimaging, 3) laboratory factors, 4) availability of antimicrobial medications, and 5) cost barriers. Efforts to improve LP uptake must incorporate interventions to increase patient/proxy willingness to consent and improve clinician LP competencies while addressing both upstream and downstream health system factors. Key upstream factors include inconsistently available consumables for performing LPs and lack of neuroimaging. Critical downstream factors include laboratory services that offer poor availability, reliability, and/or timeliness of CSF diagnostics and the reality that medications needed to treat diagnosed infections are often unavailable unless the family has resources to purchase privately.

E041 Clinicians’ levels of experience and roles influence the decisions made in telephone clinic consultations in rheumatology

Abstract Background/Aims Since the outbreak of COVID-19, clinicians adapted by switching from face-to-face to remote consultations in order to limit transmission and continue delivering high-quality outpatient services. We aimed to investigate patient- and clinician-related factors which may affect outcomes in follow-up telephone consultations. Methods Patients who attended follow-up clinic appointments via telephone consultations in the month of March 2022 were retrospectively evaluated. Data collected were demographics, main active diagnosis, current treatment and the clinicians’ grade. Factors associated with categorical outcomes i.e. decision to request a subsequent face-to-face appointment, investigations, referrals to other specialties, and to discharge a patient, were assessed using univariate logistic regression analysis. Univariate linear regression analysis was performed to identify factors associated with the length of follow-up intervals. Results 314 patients were included; 218 (69%) female, median (IQR) age 63 (53-72) years. The most common diagnosis was rheumatoid arthritis (39%). 66% of patients were on DMARDs and 16% were on steroids. There were 48 (15.3%) requests for a subsequent face-to-face appointment and 28 (8.9%) discharges. There were more investigations (20.4%) requested compared to referrals (4.5%). Specialist nurses (SpNs) were the single largest group who conducted the telephone consultations (46%). SpNs were more likely to request face-to-face appointments [odds ratio (OR) 2.16 95% CI (1.16, 4.12) P=0.017] and investigations [OR 1.77 (1.02, 3.11) P=0.043] compared to other clinicians. In contrast, consultants were less likely to request investigations [OR 0.34 (0.16, 0.66) P=0.002]. Other factors associated with a subsequent face-to-face appointment were steroid [OR 3.00 (1.45, 6.02) P=0.002] and conventional DMARD therapy [OR 2.90 (1.50, 5.92) P=0.002]. In terms of discharges, consultants were more likely to discharge a patient [OR 4.05 (1.83, 9.46) P<0.001]. Patients with a diagnosis of inflammatory arthritis [OR 0.01 (0.00, 0.06) P<0.001] and on conventional DMARDs [OR 0.03 (0.00, 0.14) P<0.001] have a lower probability of being discharged. In terms of specialty referrals, there were no significant factors identified. An analysis of 197 clinic letters which specified follow-up intervals found that consultants were more likely to request longer follow-up intervals [beta coefficient 0.32 (0.13, 0.50) P<0.001] whereas SpNs were more likely to request shorter follow-up intervals [beta coefficient -0.52 (-0.65, -0.39), P<0.001]. Conclusion These findings suggest that clinicians’ experiences and roles may influence the decisions made following a telephone clinic consultation. For example, SpNs are usually involved in drug monitoring and therefore, have a higher likelihood to request face-to-face reviews, shorter follow-up intervals and investigations. The consultant’s level of experience may explain the higher probability of discharging patients and the lower probability of requesting investigations. Further studies over a longer duration are needed to determine other factors which may affect the clinical decisions made from telephone clinic consultations. Disclosure A. Ramli: None. X. Ong: None. S. Chitale: None. E. Gladston Chelliah: None.

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.

Developing medical professionalism in care of gender nonconforming patients: Reflections of second-year medical students after a curricular experience with gender nonconforming people and allies

Introduction Negative healthcare experiences persist for gender nonconforming individuals. Clinician-related factors, including lack of comfort with gender nonconforming persons and unexamined personal biases, present barriers to equitable and affirming healthcare. We explored the effects of contact with gender nonconforming individuals in preclinical medical education through a structured curricular intervention designed to build medical and humanistic knowledge and stimulate the development of medical professionalism surrounding the care of gender nonconforming individuals. Methods A curricular module (didactic prework, time-synchronous online panel discussion, and post-event written reflection) was implemented in a second-year preclinical course in a large multi-campus Midwestern medical school. The module was based on pedagogical foundations of contact theory and reflective writing. Post-event written reflections were investigated using thematic analysis. Results Analysis of 355 written reflections revealed three major themes (moments of insight, topics of confusion, connections to professional identity formation) and eight sub-themes. The findings demonstrated emerging gender professionalism and the importance of contact in professional development. Discussion Contact with gender nonconforming people and the use of written reflections can encourage self-examination and foster professional identity formation among preclinical medical students. Modeling gender-affirming approaches may help counteract negative cultural messages about gender nonconforming people, aiding development of inclusive future physicians.

Telehealth As an Option, Not a Requirement-Who May Benefit, and How Do We Decide?

During the COVID pandemic, telehealth has been established as a feasible form of treatment that is at times preferred by both clinicians and older adult patients. As the height of the pandemic fades, yet remains part of everyday life, care has shifted in many practices from primarily video and phone visits (telemental health, or TMH) to a hybrid model that includes both virtual and in person visits. There are both advantages and potential drawbacks to TMH. Advantages include the ability to see patients who are otherwise homebound or find transportation difficult, the ability to see patients without a mask, reduction in no show rate, the potential to get a sense of the patient's home environment, and actively involving family whom the patient would like to include. Potential drawbacks include a loss of aspects of non-verbal communication, inability to perform a physical exam if needed (for example, to assess gait, check or vitals, or evaluate for extrapyramidal symptoms), potential lack of privacy, and a patient's difficulty navigating technology. Clinician related factors may also affect the success of telemental health as a treatment modality. These factors include personal preference, clinicians’ comfort with technology and the suitability of a provider's work environment for this platform. The frame of treatment (medication management versus psychotherapy) is an additional factor that must be considered. There are also individual patient characteristics that may contribute to them being more or less receptive to this modality of treatment. These factors will be highlighted in case examples in the session. Now that clinicians have a choice about meeting virtually or in person, it will be helpful to have a framework for making this decision. In this workshop, we will present guidelines for evaluating the usefulness of video delivered treatment. We will propose factors to be considered by clinicians to evaluate an individual patient's suitability for tele health versus in person or a hybrid model. We will also discuss strategies to overcome potential barriers.

Factors associated with HIV testing in people aged ⩾50 years: an integrated qualitative analysis of patients and healthcare providers.

Older people continue to be disproportionately affected by late HIV diagnosis, which results in increased morbidity and mortality. Despite high acceptance of HIV testing generally, older people are less likely to undergo testing than younger people. Two previous studies have been conducted, one focussing on patient-related and one focussing on clinician-related factors associated with HIV testing in older age (⩾50 years). This study is an integrated analysis from two linked studies - one focussed on patients, and one focussed on clinicians - to understand overlap in views and experiences of HIV testing in older age, to outline the clinical implications of the findings, and to highlight potential interventions to improve testing in this group. This qualitative study utilised semi-structured interviews conducted with 20 clinicians who were not HIV care specialists, but who had recently seen an older person prior to their HIV diagnosis, and 20 people who had been diagnosed late with HIV aged 50+. Interviews were audio recorded, transcribed verbatim and thematically analysed. The combined synthesis reported here was planned a priori as part of a sequential design. Seven clinician- and seven patient-related themes were associated with undergoing HIV testing in older age. This article discusses the four themes that were common to both groups: poor knowledge, incorrect symptom attribution, inaccurate perception of risk, and stigma. Both clinician and patient factors associated with testing will have to be addressed in order to increase HIV testing in older people, and reduce the likelihood of late diagnosis. Findings from overlapping themes suggest several areas for intervention: (1) routine screening as part of existing clinical contacts aimed at older people to eliminate the need to attribute symptoms to HIV or assess risk; (2) specific and tailored education materials for clinicians and older people which utilise appropriate modalities; (3) tailored HIV testing services: either specific clinics for older people at existing sexual health services, or dedicated services in primary care.

Managing agitation during early recovery following traumatic brain injury: qualitative interviews with clinicians

Purpose Agitated behaviours pose a significant challenge during early recovery following traumatic brain injury (TBI). This study aimed to gain a deeper understanding of how clinicians worldwide manage post-TBI agitation. Understanding the factors that influence how clinicians manage agitation can help inform the use of consistent and effective management strategies for reducing agitation in TBI care. Methods Using a qualitative design, semi-structured interviews were conducted with 33 clinicians (58% female, aged 23–71 years) from 16 countries who had experience working with agitated patients. The interviews explored the approaches used to manage agitation during early TBI recovery. Results Interviews were analysed using thematic analysis. The central theme of the interviews was the effective management of agitation, consisting of three sub-themes: managing the safety of staff and patients, reducing triggers for agitation, and implementing behavioural principles for managing agitation. Two overarching themes influenced the effective management of agitation: clinician-related factors and systemic factors. Conclusions This study highlighted key approaches for effective agitation management during early TBI recovery, as described by clinicians working with these patients worldwide. There were similarities in the strategies described, although there were many challenges that impeded the consistent implementation of such strategies in TBI care settings. IMPLICATIONS FOR REHABILITATION Effective management of agitation during early traumatic brain injury (TBI) recovery continues to pose a significant challenge for clinicians worldwide. Healthcare services may improve the management of agitation by involving the patient’s family in care delivery and implementing low-cost less-restrictive non-pharmacological interventions to reduce reliance on pharmacological interventions. Proactively addressing and removing potential sources of agitation (patient-related and environmental) may help reduce the risk of agitation occurring. The use of simple behaviour management strategies may be effective for reducing agitation, but strategies need to be implemented consistently and the approach should be flexible and tailored to the patient. Clinicians should develop an understanding of a patient’s premorbid behaviours and interests to best inform the management approach. Management of agitation may be improved by increasing clinicians’ agency in responding to agitated behaviours, through the provision of information and resources, ongoing training and skill development, supervision and support.

A Quantitative Study of Decision Thresholds for Initiation of Antibiotics in Suspected Sepsis.

Clinicians' decision thresholds for initiating antibiotics in patients with suspected sepsis have not been quantified. We aimed to define an average threshold of infection likelihood at which clinicians initiate antibiotics when treating a patient with suspected infection and to evaluate the influence of severity of illness and clinician-related factors on the threshold. This was a prospective survey of 153 clinicians responding to 8 clinical vignettes constructed from real-world data from 3 health care systems in the United States. We treated each hour in the vignette as a decision to treat or not treat with antibiotics and assigned an infection probability to each hour using a previously developed infection prediction model. We then estimated decision thresholds using regression models based on the timing of antibiotic initiation. We compared thresholds across categories of severity of illness and clinician-related factors. Overall, the treatment threshold occurred at a 69% probability of infection, but the threshold varied significantly across severity of illness categories-when patients had high severity of illness, the treatment threshold occurred at a 55% probability of infection; when patients had intermediate severity, the threshold for antibiotic initiation occurred at an infection probability of 69%, and the threshold was 84% when patients had low severity of illness (P < 0.001 for group differences). Thresholds differed significantly across specialty, highest among infectious disease and lowest among emergency medicine clinicians and across years of experience, decreasing with increasing years of experience. The threshold infection probability above which physicians choose to initiate antibiotics in suspected sepsis depends on illness severity as well as clinician factors. Incorporating these context-dependent thresholds into discriminating and well-calibrated models will inform the development of future sepsis clinical decision support systems. Clinician-related differences in treatment thresholds suggests potential unwarranted variation and opportunities for performance improvement. Decision making about antibiotic initiation in suspected sepsis occurs under uncertainty, and little is known about clinicians' thresholds for treatment.In this prospective study, 153 clinicians from 3 health care systems reviewed 8 real-world clinical vignettes representing patients with sepsis and indicated the time that they would initiate antibiotics.Using a model-based approach, we estimated decision thresholds and found that thresholds differed significantly across illness severity categories and by clinician specialty and years of experience.