Future Patient Encounters Research Articles

Standardized Anesthesia InductioN Tool (SAINT) - The development and international adoption of an integrated electronic tool for documenting the induction of anesthesia in children.

The induction of anesthesia in children poses a challenge for the anesthesiologist, the parent and child. Anxiety and negative behaviours and strategies that effectively mitigate should be documented accurately and be available for future patient encounters. To address the need for a structured and standardized electronic documentation tool. Our aim was to develop a comprehensive electronic tool to capture and report behaviours during induction of anesthesia. We performed a literature search on existing validated tools for documenting behaviours during anesthesia induction. We used the nominal group technique to achieve agreement on the components to include. We used Agile software development techniques to design and review the integrated electronic tool. Twelve international hospitals informed the development of the tool. We developed an electronic tool, the Standardized Anesthesia InductioN Tool (SAINT). SAINT incorporates validated scales for documenting key stages of the anesthesia induction journey (separation from caregivers, mask acceptance, induction behaviour, parental presence, the use of adjuncts and their effectiveness). In addition, the standardised data elements used in SAINT allow for local reporting, quality metrics and can assist in data across multi-centre trials. To date the tool has been adopted by 133 institutions across four countries and is freely available. We show that collaborative development and rapid adoption of the comprehensive induction tool SAINT has led to its rapid adoption in the routine practice of pediatric anesthesiology across several countries. Further studies on how the SAINT is being used for quality improvement or research are warranted.

Interprofessional team-based collaboration between designated GPs and care home staff: a qualitative study in an urban Danish setting

BackgroundBeing a general practitioner for residents in many care homes may challenge communication with residents, relatives, and care home staff, and potentially lead to lower quality of care. Several countries have therefore introduced different solutions to reduce the number of general practitioners at each care home. In 2017, the designated general practitioner model was introduced at many Danish care homes. This study aimed to evaluate experiences from the interprofessional team-based collaboration between designated general practitioners and care home staff with regular contact with the designated general practitioners in an urban Danish setting.MethodsA qualitative design was applied using semi-structured interviews. Eight interviews (three group interviews and five individual interviews) were conducted with four designated general practitioners and seven care home staff members at four care homes in an urban setting of Central Denmark Region, Denmark. The interviews were transcribed verbatim, and data were analysed using content analysis with inspiration from the theory of relational coordination. The study followed the guidelines addressed in the COREQ (Consolidated Criteria for Reporting Qualitative Research) framework.ResultsThe initiation of the designated general practitioner model was experienced to contribute to more clear, precise, and timely communication between care homes and the general practitioner. An improved mutual acknowledgement of roles and competencies was experienced between designated general practitioners, care home nurses, and sometimes also social and health care assistants. The more frequent visits by the general practitioners at the care homes, as a result of the designated general practitioner model, resulted in more face-to-face communication between care home staff and designated general practitioners. Professional differences in the interpretation of the patient’s needs were still present, which at times caused a frustrating compromise of own professional competencies. An important reason for the overall perception of improved collaboration was attributed to the more frequent dialogue in which the care homes staff and the designated general practitioners exchanged knowledge that could be applied in future patient encounters.ConclusionThe designated general practitioner model implied an improved collaboration between general practitioners and care homes staff. Clear, precise, and timely communication between care homes and the general practitioners, as well as mutual trust and acknowledgement was experienced to be essential for the collaboration. An important reason for the overall perception of an improved collaboration was attributed to the more frequent dialogue (more frequent general practitioner visits at the care homes) in which the care homes staff and the designated general practitioners exchange knowledge which again could be applied in future patient encounters.

A new student-led digital drawing course: an initiative to bridge patient health literacy through medical illustrations

Many physicians believe illustrations can be helpful in patient encounters, but fail to create such drawings due to a perceived lack of artistic ability. Digital drawing platforms, however, have the ability to compensate for the lack of artistic skills. Our study sought to evaluate how digital drawing instruction would impact the likelihood of medical students to utilise illustrations in future patient encounters. ‘Draw Your Way Through Medicine’ was an elective course, offered at the Icahn School of Medicine at Mount Sinai in 2020. The course instructed students how to create digital drawings using Procreate and how to depict specific surgical procedures. Students completed pre-and post-course surveys, which were analysed using paired t-tests. Thirty-six students enrolled in the course, of which 27 completed the pre-course survey and 21 completed both pre-and post-course surveys. Students’ comfort level with drawing improved somewhat (3.0 to 3.5, p = .08), while their comfort level with creating medical illustrations improved significantly (2.2 to 3.7, p < .01). Qualitative responses echoed the enthusiasm for implementing digital drawing as a clinical communication tool. A digital drawing course showed considerable value in improving medical students’ confidence in generating medical illustrations, making this form of visual communication a potentially valuable tool in patient care.

Communicating value to patients-a high-value care communication skills curriculum

ABSTRACT Introduction With rising health care costs in the United States, trainees will be increasingly challenged in discussing testing stewardship with patients. Objective We piloted a high-value care (HVC) communication skills curriculum utilizing the Four Habits Model for communication. We hoped residents would 1) learn to apply the Four Habits communication model to HVC discussions with standardized patients (SP) and 2) improve value-based communication skills through training in a high-intensity curriculum with feedback from trained faculty facilitators and peers. Methods Thirty interns at the University of Minnesota were randomized to a standard HVC communication SP encounter (n = 15) or a high-intensity HVC communication skills curriculum (n = 15). The high-intensity curriculum included video and audio-recorded SP encounters followed by facilitated small group discussions/feedback. Experiences were reported in a post-intervention survey; communication skills were assessed with the CARE empathy scale. Results 70% (21/30) of interns (57% high intensity, 43% standard) responded to the survey. In total, 88% of high intensity v. 44% of standard interns agreed/strongly agreed that the curriculum was valuable for their communication skills. High-intensity interns were more likely to report that feedback was valuable with subsequent incorporation of feedback into future patient encounters. High-intensity participants also reported higher levels of interest in future HVC curricula (55% vs 22%). Conclusion There was no difference in overall performance on the CARE empathy scale. Our HVC high-intensity skills curriculum was well received by interns and provided opportunities to practice structured conversations and debrief around testing stewardship.

Predisposition for Empathy, Intercultural Sensitivity, and Intentions for Using Motivational Interviewing in First Year Pharmacy Students

Objective. To assess first-year pharmacy (P1) students' predispositions (eg, perceptions for empathy, intercultural sensitivity, and motivational interviewing (MI) as a patient-centered communication skillset) and identify potential curricula content/communication skills training needs. Methods. A cross-sectional survey was used to collect students' self-reported perceptions for empathy, intercultural sensitivity, counseling contexts, and projected future MI use. Relationships between variables were explored and logistic regression was used to evaluate intention for using MI in future patient encounters. Results. There were 134 students who participated. Higher predisposition for empathy and for intercultural sensitivity were significantly correlated. Significant predictors for applying MI in future patient encounters were sex, confidence with counseling skills, and current use of MI. Conclusion. Results suggest the need to incorporate innovative training strategies in communication skills curricula. Potential areas include empathy, intercultural sensitivity and significant predictor variables for future MI use. Further investigation in other schools is needed.

Medical Students Can Improve Health Literacy: Training Students to Educate Patients About Obstetric Venous Thromboembolism Prophylaxis

BACKGROUND: Medical schools are increasingly emphasizing patient education in the clerkship year. Effective education is essential to increase patient buy-in when spearheading quality initiatives. This project was designed to train 3rd-year medical students in teach-back education while concurrently enhancing a departmental QI effort to increase obstetric VTE prophylaxis. METHODS: Ob-Gyn clerkship students watched a student-created instructional video on teach-back teaching and a case-based presentation on VTE prophylaxis. Students assessed three patients for VTE risk and counseled patients on interventions. Students recorded pre- and postcounseling assessments of patient knowledge and responded to a survey about their experience. RESULTS: During the first clerkship block, 26 students participated in counseling and 75 patients were counseled. Following student counseling, a significantly increased number of patients exhibited understanding of: definition and consequences of VTE (56.25% increase, P&lt;.0001), VTE risk factors (212.5% increase, P&lt;.0001) and prophylactic interventions (169% increase, P&lt;.0001). Students agreed or strongly agreed that their participation improved: understanding of VTE prophylaxis (100%), confidence counseling patients (100%), quality of patient care (64%), and understanding of QI (93%). One hundred percent of students stated that they plan to use teach-back teaching in future patient encounters. DISCUSSION: Students felt that the experience was rewarding and contributed to their education, and students' assessment of patient understanding improved following counseling. This intervention demonstrates that medical students can effectively counsel patients and enhance a quality improvement intervention.

Applying sport psychology to improve clinical performance

Preparedness for practice has become an international theme within Medical Education: for healthcare systems to maintain their highest clinical standards, junior doctors must “hit the ground running” on beginning work. Despite demonstrating logical, structured assessment and management plans during their undergraduate examinations, many newly qualified doctors report difficulty in translating this theoretical knowledge into the real clinical environment. “Preparedness” must constitute more than the knowledge and skills acquired during medical school. Complexities of the clinical environment overwhelm some junior doctors, who acknowledge that they lack strategies to manage their anxieties, under-confidence and low self-efficacy. If uncontrolled, such negative emotions and behaviors may impede the delivery of time-critical treatment for acutely unwell patients and compound junior doctors’ self-doubt, thus impacting future patient encounters. Medical Education often seeks inspiration from other industries for potential solutions to challenges. To address “preparedness for practice,” this AMEE Guide highlights sport psychology: elite sportspeople train both physically and psychologically for their discipline. The latter promotes management of negative emotions, distractions and under-confidence, thus optimizing performance despite immense pressures of career-defining moments. Similar techniques might allow junior doctors to optimize patient care, especially within stressful situations. This AMEE Guide introduces the novel conceptual model, PERFORM, which targets the challenges faced by junior doctors on graduation. The model applies pre-performance routines from sport psychology with the self-regulatory processes of metacognition to the clinical context. This model could potentially equip junior doctors, and other healthcare professionals facing similar challenges, with strategies to optimize clinical care under the most difficult circumstances.

Pharmacy students’ perceptions of the usefulness of motivational interviewing and the use of mobile health applications on patient counseling in the future

IntroductionTo explore student pharmacists’ perceptions of 1) future patient counseling, 2) use of mobile health applications (mHealth apps), and 3) usefulness of motivational interviewing (MI) in patient encounters and potential app messaging. MethodsA cross-sectional design with first and second year pharmacy students (n=315) at a multi-campus university after exposure to mHealth app and MI curricular content. A questionnaire assessed perceptions of 1) future patient counseling, 2) using apps for personal use and professional encounters, and 3) potential practicality and usefulness of MI principles/skills in apps messaging. ResultsOver 70% of students perceived they will be counseling future patients for medication therapy/comprehensive disease management; 91% believed it is an important role as a future pharmacist. A majority own a smartphone (98%), have used an mHealth app to monitor/change a health behavior (73%), and are likely to recommend an mHealth app in future patient encounters (90%). Perceptions of counseling importance and likelihood to recommend an mHealth app varied by gender (women higher than men, p<0.01, p<0.01) and previous mHealth app use (yes higher than no, p<0.05, p<0.001). Most students reported a high likelihood of incorporating MI into current (88%) and future (91%) patient encounters and particularly noted ‘supporting self-efficacy’ as a useful MI principle to incorporate into mHealth app messaging. Discussion and conclusionsThose using apps for personal health behavior change(s) perceived future patient counseling as important and were more likely to recommend mHealth apps during those future encounters. Results may inform curricular development to prepare future pharmacists for the high-tech, patient-centered practice that is inevitable.

Neurologic Deep Dive: A Simulation Case of Diagnosing and Treating Decompression Sickness for Emergency Medicine Residents.

Decompression sickness (DCS) is a rare and dangerous complication from a rapid decrease in environmental pressure, commonly seen in patients leaving a compressed-air environment, such as scuba divers, aviators, and deep tunnel workers. Failure to clinically diagnose and adequately treat DCS with hydration and supplemental oxygen before bridging to hyperbaric oxygen (HBO) therapy can result in permanent residual symptoms or, in rare cases, death. Despite the increasing incidence of DCS, there are limited published simulation case studies discussing this perilous environmental exposure. This fictional simulation case is written for emergency medicine residents to diagnose and manage DCS from a live-actor patient presenting with unilateral neurologic symptoms and concealed cyanotic mottling (cutis marmorata). This case ran for four separate iterations at a simulation center, with a resident, fellow, and attending acting as specific confederates for their respective roles. Following each case, the learners were debriefed at bedside, discussed a PowerPoint presentation, and underwent a question-and-answer session. Based on postsimulation qualitative assessments, junior and senior residents correctly identified DCS, but junior residents alone were less likely to elicit pertinent social history or to fully physically examine the patient without the presence of senior residents. Both resident groups were able to verbally explain the fundamental DCS pathophysiology to the patient, but junior residents were unable to specifically direct oxygenation, hydration, and HBO protocols for DCS. After case completion and debriefing, all learners demonstrated achievement of primary learning objectives. Overall, we noted this case worked well for junior EM residents with senior-resident backup. Both learner groups appreciated the concealed elements of case, including scuba diving history and exposed dermatologic findings, and reported that these were invaluable learning moments for all future patient encounters, not just those limited to DCS.

Teaching at the Bedside. Maximal Impact in Minimal Time.

Academic physicians encounter many demands on their time including patient care, quality and performance requirements, research, and education. In an era when patient volume is prioritized and competition for research funding is intense, there is a risk that medical education will become marginalized. Bedside teaching, a responsibility of academic physicians regardless of professional track, is challenged in particular out of concern that it generates inefficiency, and distractions from direct patient care, and can distort physician-patient relationships. At the same time, the bedside is a powerful location for teaching as learners more easily engage with educational content when they can directly see its practical relevance for patient care. Also, bedside teaching enables patients and family members to engage directly in the educational process. Successful bedside teaching can be aided by consideration of four factors: climate, attention, reasoning, and evaluation. Creating a safe environment for learning and patient care is essential. We recommend that educators set expectations about use of medical jargon and engagement of the patient and family before they enter the patient room with trainees. Keep learners focused by asking relevant questions of all members of the team and by maintaining a collective leadership style. Assess and model clinical reasoning through a hypothesis-driven approach that explores the rationale for clinical decisions. Focused, specific, real-time feedback is essential for the learner to modify behaviors for future patient encounters. Together, these strategies may alleviate challenges associated with bedside teaching and ensure it remains a part of physician practice in academic medicine.

Medical students as hospice volunteers: reflections on an early experiential training program in end-of-life care education.

Despite an increase in the content of palliative medicine curricula in medical schools, students are rarely exposed to end-of-life (EOL) care through real-patient experiences during their preclinical education. To evaluate the utility and impact of exposure to EOL care for first year medical students (MS-1s) through a hospice volunteer experience. Patients and Families First (PFF), a hospice volunteer training program in EOL care, was piloted on three cohorts of MS-1s as an elective. Fifty-five students received 3 hours of volunteer training, and were then required to conduct at least two consecutive hospice visits on assigned patients to obtain course credit. Students' reflective essays on their experiences were analyzed using qualitative methodology and salient themes were extracted by two investigators independently and then collaboratively. The following five themes were identified from students' reflective essays: perceptions regarding hospice patients; reactions regarding self; normalcy of EOL care at home; impact of witnessing death and dying; and suggestions for improving EOL care education for medical students. Hospice volunteering during preclinical years may provide valuable experiential training for MS-1s in caring for seriously ill patients and their families by fostering personal reflection and empathic skills, thereby providing a foundation for future patient encounters during clinical training.

Improving Efficiency of Clinical Skills Training: A Randomized Trial

The rising number of medical students and the impact this has on students' learning of clinical skills is a matter of concern. Cooperative learning in pairs, called dyad training, might help address this situation. The aim of this study was to evaluate the effect of dyad training on students' patient encounter skills. Experimental, randomized, observer-blinded trial. Forty-nine pre-clerkship medical students without prior clinical experience. All students underwent a 4-h course on how to manage patient encounters. Subsequently, the students were randomized into a dyad practice group (n = 24) or a single practice group (n = 25). Both groups practiced for 4 h on four different case scenarios, using simulated patients. Students in the dyad group practiced together and took turns as the active participant, whereas students in the single group practiced alone. Performance tests of patient encounter skills were conducted 2 weeks after the training by two blinded raters. Students had no clinical training during those weeks. A questionnaire-based evaluation surveyed students' confidence in their patient management skills. The dyad group scored significantly higher on the performance test, mean 40.7 % (SD 6.6), than the single group, mean 36.9 % (SD 5.8), P = 0.04, effect size 0.61. Inter-rater reliability was 0.69. The dyad group expressed significantly higher confidence in managing future clinical patient encounters than the single group, mean 7.6 (SD 0.9) vs. mean 6.5 (SD 1.1), respectively, P < 0.001, effect size 1.16. Dyad training of pre-clerkship medical students' patient encounter skills is effective, efficient, and prompts higher confidence in managing future patient encounters compared to training alone. This training format may help maintain high-quality medical training in the face of an increasing number of students in medical schools.

Comparison of three problem-based learning conditions (real patients, digital and paper) with lecture-based learning in a dermatology course: A prospective randomized study from China

Background: The precise effect and the quality of different cases used in dermatology problem-based learning (PBL) curricula are yet unclear.Aim: To prospectively compare the impact of real patients, digital, paper PBL (PPBL) and traditional lecture-based learning (LBL) on academic results and student perceptions.Methods: A total of 120 students were randomly allocated into either real-patients PBL (RPBL) group studied via real-patient cases, digital PBL (DPBL) group studied via digital-form cases, PPBL group studied via paper-form cases, or conventional group who received didactic lectures. Academic results were assessed through review of written examination, objective structured clinical examination and student performance scores. A five-point Likert scale questionnaire was used to evaluate student perceptions.Results: Compared to those receiving lectures only, all PBL participants had better results for written examination, clinical examination and overall performance. Students in RPBL group exhibited better overall performance than those in the other two PBL groups. Real-patient cases were more effective in helping develop students’ self-directed learning skills, improving their confidence in future patient encounters and encouraging them to learn more about the discussed condition, compared to digital and paper cases.Conclusion: Both real patient and digital triggers are helpful in improving students’ clinical problem-handling skills. However, real patients provide greater benefits to students.

Introduction of real patients into problem-based learning in preclinical first-year anatomy curriculum

Background: Early patient contacts are considered important in medical education.Aims: We studied the influence of a real patient trigger on study motivation and learning in problem-based study groups of first-year medical and dentistry students.Methods: 156 eligible students were allocated into 17 groups. Six randomly selected groups received both the real patient and paper trigger, and 11 groups received only the paper trigger. The immediate and later effects of the trigger were assessed with qualitative and quantitative questionnaires and exam scores. The tutors answered questionnaires concerning learning outcomes.Results: The students reported that the real patient trigger significantly improved their study motivation, understanding of the learning objectives and confidence in future patient encounters. The real patient trigger was considered significantly more interesting than the paper case. No statistically significant difference was observed in the exam scores. The tutors observed that groups with poor previous performance gained better results in study sessions.Conclusions: Real patient triggers motivate students to learn basic medical sciences. Ways to present real patients to students should be considered in medical curricula from early on.

Procedural Sedation in Children

Children are often fearful of visits to the emergency department (ED) because it represents a potentially painful experience in a foreign environment. Over the past 2 decades, a greater appreciation of the need to maximize patient comfort and minimize anxiety for the entire pediatric age spectrum has led to an appreciation of the role played by anxiolytics, narcotics, and sedatives in reducing unnecessary discomfort during the performance of procedures and radiologic examinations in children. The spectrum of agents available for pediatric procedural sedation and analgesia in the ED has broadened considerably over the past 2 decades. The intramuscular narcotic-phenothiazine “cocktail” has been relegated to historical lore, and the present day practitioner can choose from over a dozen pharmacologic options, enabling some finesse in matching the sedative-analgesic agents and routes of delivery to fit the clinical need. Administration of effective procedural sedation can maximize patient comfort, thus leading to a higher frequency of procedural success. In addition, because medications such as midazolam offer amnesia for the procedure, patients can undergo invasive procedures without building a fear for future patient encounters. Administration of procedural sedation is also often linked with increased parental satisfaction with the ED experience, despite the fact that the administration of sedation can be associated with increased length of stay. For all these reasons, it is safe to say that the administration of procedural sedation has become the standard of care for painful or anxiety producing procedures and certain radiologic studies. This issue of Clinical Pediatric Emergency Medicine is thus dedicated toward broadening practitioner

Breaking bad news: structured training for family medicine residents

Previous research has shown that physicians experience incompetence and difficulty in dealing with patients’ feelings after they have broken bad news to them. During the past 10 years, we have implemented a longitudinal training program targeting these issues. The present article describes this training and discusses its contribution to doctors’ skills at approaching distressed patients. In order to cope with breaking bad news to patients and their families, physicians should be skilled at crisis intervention and communication techniques. They should also be aware of their personal attitudes and emotional reactions when breaking bad news. Each session encompassed these areas, as well as the most prominent issues arising when breaking bad news. In a 1–5 Likert scale, the course received an overall score of 4.47 (S.D. 0.51). Participants noted that they had gained relevant communication skills for future patient encounters.

Brief intervention in hazardous drinking: An important adjunct to medical school ATOD curriculum

Most medical school alcohol, tobacco and other drug (ATOD) curricula emphasize the diagnosis and treatment of alcohol abuse and dependence, even though a significant amount of alcohol‐related morbidity and mortality is associated with the hazardous use of alcohol An increased emphasis on screening for hazardous drinking and the use of early intervention has been shown to be effective in reducing heavy drinking in the primary care setting. This paper describes a family medicine clerkship seminar on clinical preventive medicine that focuses on tobacco and alcohol use. Results indicate that students team that brief intervention counseling can influence patient behavior and plan to continue to use it in future patient encounters. However, the low number of students electing to intervene in hazardous drinking suggests that more cumcular time is needed to overcome student resistance to addressing the alcohol use patterns of their patients.